Plate  I. 


Davis'  Obstetrics. 


The  Abdomen  at  Term.     (Martin.) 


A  MANUAL 


OF 


PRACTICAL  OBSTETRICS. 


BY 

EDWARD  P.  DAVIS,  A.  M.,  M.  D., 

CLINICAL  LECTURER  ON  OBSTETRICS  IN  THE  JEFFERSON  MEDICAL  COLLEGE,  PROFESSOR 

OF  OBSTETRICS  AND  DISEASES  OF  CHILDREN  IN  THE  PHILADELPHIA  POLYCLINIC, 

VISITING  OBSTETRICIAN  TO  THE  PHILADELPHIA  HOSPITAL,  PHYSICIAN 

TO  THE  CHILDREN'S  DEPARTMENT  OF  THE  HOWARD  HOSPITAL, 

MEMBER  OF  THE  AMERICAN  GYNECOLOGICAL  SOCIETY. 


WITH  ONE  HUNDRED  AND  FORTY   ILLUSTRATIONS, 
TWO  OF  WHICH  ARE  COLORED. 


PHILADELPHIA: 

P.   BLAKISTON,   SON   &   CO. 

1012   WALNUT  STREET. 

l8qi. 


COPYRIGHT,  1891, 

BY 

P.  BLAKISTON,  SON  &  CO. 


PREFACE. 


THE  preparation  of  this  book  has  been  suggested  to  me 
by  the  needs  experienced  in  teaching  students  of  medicine. 
The  development  of  post-graduate  instruction,  and  the  estab- 
lishment of  obstetrics  as  a  Senior  Study  in  medical  colleges, 
have  relieved  obstetric  study  from  the  details  of  anatomy  and 
physiology  memorized  by  the  student  in  his  earlier  years. 
Whether  he  be  an  undergraduate  in  a  medical  college,  or  a 
practitioner,  he  desires  to  know  the  reasons  for  scientific  facts, 
and  the  practical  deductions  which  their  consideration  suggests. 
As  an  aid  in  such  study,  I  have  endeavored  to  give  a  concise 
statement  of  modern  practical  obstetrics  as  taught  by  Parvin, 
Lusk,  Schroder,  Winckel,  Carl  Braun,  Galabin  and  Diihrssen. 
Personal  experience  has  guided  my  choice  of  methods  of 
treatment  commended.  My  best  thanks  are  due  to  Professor 
Parvin  for  many  acts  of  courtesy  and  kindness ;  to  Dr.  Naudain 
Duer  for  assistance  in  preparing  illustrations ;  and  to  Dr.  A.  A. 
Eshner  for  the  index. 


250  S.  2ist  Street, 
Philadelphia. 


TABLE   OF   CONTENTS. 


CHAPTER.  PAGE. 

I.    OVULATION;  MENSTRUATION;  CONCEPTION;  THE  OVUM  .  9 

II.     THE  EMBRYO 15 

III.  THE  FCETUS  AND  ITS  PHYSIOLOGY 24 

IV.  THE  BIRTH  CANAL 34 

V.     THE  MOTHER  IN  PREGNANCY 43 

VI.     THE  DIAGNOSIS  OF  PREGNANCY 45 

VII.     THE  HYGIENE  OF  PREGNANCY 53 

VIII.    THE  ATTITUDE  AND  LOCATION  OF  THE  FCETUS  ....  57 

IX.     LABOR,  THE  HEAD  PRESENTING 61 

X.     ABNORMALITIES  OF  LABOR,  THE  HEAD  PRESENTING  .    .  71 

XI.    THE  TREATMENT  OF  NORMAL  LABOR 77 

XII.    THE  THIRD  STAGE  OF  LABOR 83 

XIII.  THE  TREATMENT  OF  ABNORMAL  LABORS,  THE   HEAD 

PRESENTING 88 

XIV.  THE  FORCEPS 91 

XV.     Axis  TRACTION;  THE  RARER  USES  OF  THE  FORCEPS   .  98 

XVI.    LABOR  IN  BREECH  PRESENTATIONS 109 

XVII.     LABOR  IN  TRANSVERSE  POSITIONS 120 

XVIII.     VERSION 123 

XIX.    LABOR  WHEN  THE  CHILD  AND  BIRTH   CANAL  OF  THE 

MOTHER  ARE  DISPROPORTIONATE  IN  SIZE 132 

XX.    LABOR  COMPLICATED  BY  OBSTRUCTION  IN  THE  BIRTH 

CANAL 135 

3 


4  TABLE   OF    CONTENTS. 

CHAPTER.  PAGE. 

XXI.  LABOR  IN  CONTRACTED  PELVES 139 

XXII.  ABORTION;  PREMATURE  LABOR 149 

XXIII.  INDUCED  LABOR 157 

XXIV.  MULTIPLE  PREGNANCY 161 

XXV.  PATHOLOGY  OF  PREGNANCY:  ECLAMPSIA 166 

XXVI.     THE  ACUTE  INFECTIONS  OCCURRING  DURING  PREGNANCY  175 
XXVII.    AFFECTIONS  OF  THE  GENITO  URINARY  ORGANS  OCCUR- 
RING DURING  PREGNANCY.   THE  BLOOD  AND  NERVOUS 

SYSTEM 179 

XXVIII.    THE  SURGICAL  TREATMENT  OF  COMPLICATED  LABOR    .  188 

XXIX.     EMBRYOTOMY 194 

XXX.     THE  PUERPERAL  STATE 206 

XXXI.     PUERPERAL  STATE;  LACTATION 212 

XXXII.    ARTIFICIAL  FEEDING  OF  INFANTS 217 

XXXIII.  ABNORMAL  INSERTION  OF  PLACENTA  :  PLACENTA  PR.^EVIA  222 

XXXIV.  ECTOPIC  PREGNANCY 228 

XXXV.     POST  PARTUM  HAEMORRHAGE 233 

XXXVI.     ACCIDENTS  OF  LABOR  ENDANGERING  THE  MOTHER  .    .  238 

XXXVII.     LACERATION  OF  PERINEUM  AND  PELVIC  FLOOR  .    .       .  245 

XXXVIII.     PUERPERAL  SEPSIS 251 

XXXIX.     THE  TREATMENT  OF  PUERPERAL  SEPSIS 258 

XL.     COMPLICATIONS  OF  THE  PUERPERAL  STATE 261 

XLI.    RETENTION  OF  THE  PLACENTA 266 

XLII.     DISEASE  OF  FCETAL  APPENDAGES 269 

XLIII.     DISORDERS  OF  THE  FCETUS 273 

XLIV.     MONSTERS 277 

XLV.     DISEASES  OF  NEWBORN  CHILD 279 

APPENDIX 284 

INDEX 291 


LIST  OF  ILLUSTRATIONS. 


i.— Two  GRAAFIAN  FOLLICLES. 

2. — HUMAN  OVUM. 

3.— THE  MURIFORM  BODY. 

4.— THE  DECIDUOUS  MEMBRANES. 

5. — THE  EMBRYONIC  AREA  AND  AXIAL  GROOVE. 

6. — EMBRYO,  SEVEN  OR  EIGHT  WEEKS  OLD. 

7. -OVUM  Six  WEEKS  OLD. 

8. -THE  AMNION  AND  ALLANTOIS. 

9  — VILLI  OF  CHORION  (low  power). 
:o. — VILLI  (330  diameters), 
n.- PLACENTAL  VILLI  AND  DECIDUA. 
12. — PLACENTA,  MEMBRANES  (stripped  upward). 
13.— PLACENTAL  AND  UTERINE  VESSELS. 
14.— THE  PLACENTA  AND  UTERUS  (injected  while  adherent). 
15. -THE  MEMBRANES.     (Section  through  uterine  wall.) 
16. — CROSS  SECTION  OF  CORD. 
17. — DIAGRAM  OF  THE  FCETAL  CIRCULATION. 
18.— THE  FCETAL  HEAD. 
19.— THE  FCETAL  HEAD. 
20.— THE  FCETAL  HEAD. 
21. — THE  BIRTH  CANAL. 
22. — DIAMETERS  OF  PELVIC  BRIM. 
23.— PELVIC  OUTLET. 

24.    DIAMETER  OF  BRIM,  AND  Axis  OF  BIRTH  CANAL. 
25.— Axis  OF  FCETAL  BODY,  FULCRUM,  SHORT  AND  LONG  ARM  OF  LEVER. 
26. — THE  PELVIC  MEASUREMENTS. 
27. —  INTERNAL    MEASUREMENTS  OF  THE  ANTERO-POSTERIOR   DIAMETER 

OF  THE  PELVIC  BRIM. 
28. — THE  PELVIMETER. 

29. — THE  USUAL  ATTITUDE  AND  LOCATION  OF  THE  FCETUS. 
30.— LATERAL  SURFACE  OF  THE  PELVIS. 
31.— THE  FCETUS  IN  A  PRIMAGRAVIDA. 
32. — THE  FCETUS  IN  A  MULTIGRAVIDA. 

33. — THE  DESCENT  OF  THE  FCETUS  IN  LEFT  OCCIPITO  ANTERIOR  LABOR. 
34.— THE  HEAD  ENGAGING  IN  THE  PELVIC  BRIM. 

S 


6  LIST   OF    ILLUSTRATIONS. 

35. — DESCENT  AND  ROTATION. 

36. — THE  HEAD  UPON  THE  PELVIC  FLOOR. 

37. — BEGINNING  EXPULSION  OF  THE  HEAD. 

38. — RETROCESSION  OF  COCCYX. 

39. — HEAD  BORN  IN  RIGHT  OCCIPITO-ANTERIOR  LABOR. 

40.— THE  OCCIPUT  IN  THE  HOLLOW  OF  THE  SACRUM. 

41.— FACE  PRESENTATION;    LEFT-FRONTO-ANTERIOR. 

42. — RIGHT- FRONTO-ANTERIOR. 

43. — MECHANISM  OF  FACE  PRESENTATION. 

44. — EXPULSION  OF  THE  HEAD  IN  FACE  PRESENTATION. 

45. — HEAD  BORN  IN  FACE  PRESENTATION. 

46 — EPISIOTOMY. 

47.— EPISIOTOMY  KNIFE  DEVISED  BY  THE  WRITER. 

48.— THE  PLACENTA  AND  MEMBRANES,  AFTER  THE  EXPULSION  OF  THE 
FCETUS. 

49. — THE  ABDOMEN  AFTER  THE  FCETUS  is  BORN,  THE  PLACENTA  IN  THE 
UTERUS. 

50. — THE  EXPULSION  OF  THE  PLACENTA,  FCETAL  SURFACE  FIRST. 

51. — THE  PLACENTA  IN  THE  LOWER  UTERINE  SEGMENT. 

52.— DAVIS  FORCEPS,  PERFORATED  FOR  Axis  TRACTION  TAPES. 

53. — THE  LEFT  HAND  GRASPING  THE  LEFT  FORCEPS  BLADE. 

54.— THE  INTRODUCTION  OF  THE  LEFT  BLADE  COMPLETED. 

55. — PROTECTION  OF  THE  PERINEUM  IN  FORCEPS  DELIVERY,  THE 
PATIENT  UPON  THE  LEFT  SIDE. 

56.— Axis  TRACTION. 

57. — LUSK'S  TARNIER'S  AXIS-TRACTION  FORCEPS. 

58. — TARNIER'S  LATEST  AXIS-TRACTION  FORCEPS. 

59. — SIMPSON'S  AXIS-TRACTION  FORCEPS. 

60. — SIMPSON'S  FORCEPS,  WITH  POULLET  TAPE  ATTACHMENT  FOR  AXIS- 
TRACTION. 

61. — BREECH  PRESENTATION,  THE  LEGS  EXTENDED.    (First  position.) 

62. — DESCENT  OF  THE  TRUNK,  BREECH  PRESENTATION.  (Second  position.) 

63.— THE  SHOULDERS  EMERGING,  BREECH  PRESENTATION.  (Second  position.) 

64.— EXPULSION  OF  THE  HEAD  IN  BREECH  CASES. 

65.— HEAD  BORN  IN  BREECH  LABOR. 

66. — BRINGING  DOWN  THE  HIPS  IN  A  DELAYED  BREECH  LABOR. 

67. — BRINGING  DOWN  THE  TRUNK  IN  BREECH  CASES. 

68.— THE  ARMS  BESIDE  THE  HEAD. 

69. — THE  ARMS  BESIDE  THE  HEAD. 

70. — DELIVERING  THE  ARMS. 

71.— THE  DELIVERY  OF  THE  AFTER-COMING  HEAD.    (A.) 

71.— ATTEMPTED  SPONTANEOUS  EVOLUTION  IN  TRANSVERSE  POSITION.  (B.) 

72.— RIGHT  DORSO- ANTERIOR. 

73.— RIGHT  DORSO -POSTERIOR. 

74. — COMBINED  VERSION,  (First  stage). 


LIST   OF    ILLUSTRATIONS.  7 

75. — COMBINED  VERSION,  (Second  stage). 

76.— COMBINED  VERSION,  (Third  stage). 

77.— INTERNAL  VERSION,  (Grasping  the  lower  foot). 

78. — INTERNAL  VERSION,  (Grasping  the  upper  foot). 

79.— INTERNAL  VERSION,  (Grasping  both  feet). 

80.— THE  NOOSE  IN  VERSION. 

81. — THE  OBSTETRICIAN  ANESTHETIZING  THE  PATIENT  AND  PERFORM- 
ING VERSION  WITHOUT  ASSISTANCE. 

82. — SYMMETRICALLY  SMALL  (Justo-Minor)  PELVIS. 

83. — THE  POSTURE  AND  ABDOMINAL  PROTRUSION  IN    A  WELL-FORMED 
PREGNANT  WOMAN. 

84. — POSTERIOR  SURFACE  OF  A  WELL-FORMED  FEMALE  BODY. 

85.— HEAD  ENTERING  A  FLAT  PELVIS. 

86. — FLAT  PELVIS,  THE  HEAD  PASSING  THROUGH  AFTER  VERSION. 

87. — FLAT  RHACHITIC  PELVIS. 

88.— FLAT  RHACHITIC  PELVIS. 

89 — ATTITUDE  AND  ABDOMINAL  PROTRUSION  (Pendulous  Abdomen)  OF 
WOMAN  WITH  RHACHITIC  PELVIS. 

90. — SPONDYLOLISTHETIC  PELVIS. 

91. — OBLIQUELY  CONTRACTED  PELVIS  FOLLOWING  FRACTURE. 

92.— OVUM  OF  Two  MONTHS  INTACT. 

93. — SAME  OVUM,  THE  DECIDUOUS  MEMBRANES  OPENED  SHOWING  VILLI 
OF  CHORION. 

94.— SMELLIE'S  SCISSORS. 

95. — BLOT'S  PERFORATOR. 

96.— LUSK'S  CEPHALOTRIBE. 

97. —  MARTIN'S  STRAIGHT  TREPHINE. 

98. — FCETAL  HEAD  TREPHINED  AND  DELIVERED  BY  CRANIOCLAST. 
99.— GRASPING  THE  HEAD  WITH  THE  CRANIOCLAST. 

loo. — BRAUN'S  CRANIOCLAST. 

101. — CRANIOTOMY  WITH  THE  SIMPLE  PERFORATOR. 

102. — CRANIOTOMY  WITH  THE  TREPHINE. 

103. — DECAPITATION  ;    TIGHTENING  A  CORD  AROUND  THE  NECK. 

104.— BRAUN'S  DECAPITATION  HOOK. 

105. — DECAPITATION  WITH  BRAUN'S  HOOK. 

106. — TARNIER'S  BASIOTRIKE. 

107. — PLACENTA  PREVIA  CENTRALIS,  INTRODUCING  THE  HAND  TO  BRING 
DOWN  THE  FEET. 

108.— COMBINED  VERSION,  (Pushing  up  the  Head). 

109. — COMBINED  VERSION,  (Bringing  down  the  Legs). 

no. — TUBAL  PREGNANCY. 

in. — TAMPONING  THE  UTERUS  FOR  HEMORRHAGE. 

i la.—  THREATENED  UTERINE  RUPTURE. 

113.— VERSION  IN  THREATENED  RUPTURE  OF  THE  UTERUS. 

114. — INVERSION  OF  THE  UTERUS. 


8  LIST   OF   ILLUSTRATIONS. 

115. — METHODS  OF  CLOSING  LACERATION  OF  THE  PERINEUM. 
116. — METHODS  OF  CLOSING  LACERATION  OF  THE  PERINEUM. 
117. — METHODS  OF  CLOSING  LACERATION  OF  THE  PERINEUM. 
118. — METHODS  OF  CLOSING  LACERATION  OF  THE  PERINEUM. 
119.— METHODS  OF  CLOSING  LACERATION  OF  THE  PERINEUM. 
120. — METHODS  OF  CLOSING  LACERATION  OF  THE  PERINEUM. 
121. — METHODS  OF  CLOSING  LACERATION  OF  THE  PERINEUM. 
122. — METHODS  OF  CLOSING  LACERATION  OF  THE  PERINEUM. 
123. — HARD  RUBBER  INTRA-UTERINE  DOUCHE  TUBE. 
124.— REPLACING  THE  CORD  WITH  A  CATHETER. 
125.— LABOR  DELAYED  BY  HYDROCEPHALIC  HEAD. 
126. — HYDROCEPHALUS  AND  BREECH  PRESENTATION. 
127. — ANENCEPHALIC  MONSTER. 
128.— FCETAL  BONE,  SYPHILIS,  (Showing  Syphilitic  lines). 


LIST  OF  PLATES. 


PAGE 

I.  THE  ABDOMEN  AT  TERM   (Martin} Frontispiece 

II.  SUPPLEMENTARY   DIAGNOSIS  OF  THE  COURSE  OF  LABOR  FROM 

THE   SHAPE    OF    THE    SKULL   OF    THE    NEW    BORN   CHILD 
(Olsha'iseri)      

III.  FLAT  RHACHITIC  PELVIS  (Martin} 

IV.  NORMAL  AND  CONTRACTED  PELVES  (Martin} 

V.  RHACHITIC,   ANCHYLOSED,  OSTEOMALACIC  AND    CONTRACTED 

PELVES  (Martin) 

VI.  UTERUS  WITH  TWINS  IN  CRANIAL  AND  BREECH  PRESENTATION 

(Smellie) 

VII.  FLEXIONS  AND  RETROVERSIONS  OF  UTERUS  i  (Martin)   .... 

VIII.  FLEXIONS  AND  RETROVERSIONS  OF  UTERUS  n  (Martin)  .... 

IX.  NARROWING  OF  THE  VAGINA  BY  AN  OVARIAN  TUMOR  (Martin) 

Colored 

X.  TRANSVERSE   RUPTURE  OF  THE   ANTERIOR   CERVICAL  WALL 

(Spiegelberg}  Colored 

XI.  SEAT  OF  PLACENTA  OVER  Os  UTERI,  FROM  BODY  OF  A  WOMAN 

WHO    HAD    DIED   OF    UTERINE    H/EMORRHAGE   IN    THE    NINTH 

MONTH  OF  PREGNANCY,  PLACENTA  PR.^VIA  CENTRALIS  (Mar- 
tin)     


MANUAL  OF  PRACTICAL  OBSTETRICS. 


CHAPTER    I. 
OVULATION;  MENSTRUATION;  CONCEPTION;  THE  OVUM. 

BY  Ovulation  is  understood  the  formation  in  the  ovaries  and  dis- 
charge from  those  organs  of  the  ova  or  eggs,  from  which  the  human 
being,  in  common  with  other  mammals,  is  produced.  This  pro- 
cess does  not  occur  at  regular  intervals,  but  goes  on  almost  con- 
stantly from  the  establishment  of  puberty  to  the  menopause  and 
even  later.  Menstruation  is  a  discharge  of  blood  and  epithelial 
elements  from  the  uterine  decidua  which  occurs  at  intervals,  usu- 
ally twenty-eight  days  each,  but  frequently  is  intermitted. 

The  relation  between  ovulation  and  menstruation  may  be  ex- 
pressed by  the  statement  that  a  woman  may  ovulate  without  men- 
struation, but  she  will  rarely  menstruate  without  ovulation. 

The  discharge  of  blood  occurring  after  removal  of  the  ovaries 
or  operations  upon  the  pelvic  organs  is  not  menstruation,  but 
uterine  hemorrhage,  as  it  is  not  caused  by  the  exfoliation  of  the 
endometrium,  and  does  not  contain  the  cellular  elements  of  the 
menstrual  fluid. 

Pregnancy  causes  menstruation  to  cease,  as  may  also  any  cause 
which  disturbs  the  general  health,  while  ovulation  may  continue 
and  a  second  conception  occur  prior  to  the  formation  of  the 
decidual  membrane  in  the  first  fecundated  ovum  ;  conception  also 
takes  place  during  the  temporary  cessations  of  menstruation  which 
follow  change  of  climate  or  great  alteration  in  a  patient's  environ- 
ment. Conception  is  the  union  of  the  male  and  female  elements, 

9 


10 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


the  joining  of  the  spermatozoid  of  the  male  semen  with  the  fe- 
male ovum.  When  the  woman's  body  contains  this  united  ele- 
ment she  is  pregnant.  To  understand  this  condition  known  as 
pregnancy  the  anatomy  of  the  ovum,  the  manner  of  its  discharge 
from  the  ovary,  and  the  site  and  mode  of  impregnation  must  be 
considered  (Fig.  i). 

FIG.  i. 


Two  GRAAFIAN  FOLLICLES. 

tn.  g.  Membrana  granulosa.     j.  t.  Ovarian  stroma.    p.  d.  Proligerous  disc. 

The  ovaries  contain  the  ova  in  ovisacs,  called  from  their  dis- 
coverer Graafian  follicles.  The  capsule  of  a  follicle  is  lined  by 
round  nucleated  cells  named  the  granular  membrane  (Membrana 
Granulosa).  At  some  portion  of  the  wall  of  the  follicle  these 
cells  accumulate,  forming  the  proligerous  disc  in  which  is  found 
the  ovum.  This  little  body,  TZTT  of  an  inch  in  diameter,  is  com- 
posed of  a  yelk  membrane  (the  vitelline  membrane) ,  a  yelk  (the 
vitellus),  a  transparent  vesicle  (the  germinal  vesi- 
cle), in  the  centre  of  which  is  the  germinal  spot ; 
the  germinal  vesicle  measures  7^  of  an  inch  in 
diameter;  the  germinal  spot  raW,  about  the  size 
of  a  red  blood  corpuscle  (Fig.  2). 

The  ova  are  discharged  from  the  ovaries  by 
rupture  of  the  ovisacs,  and  pass  thence  through 
the  oviducts  to  the  uterus;  or,  meeting  the 
spermatozoids,  may  remain  and  develop  in  some 
.portion  of  the  duct  of  the  ovary.  These  ducts, 


FIG.  2. 


HUMAN  OVUM. 

1.  Germinal  vesicle. 

2.  Yelk. 


OVULATION;  MENSTRUATION;  CONCEPTION;  THE  OVUM,     n 

called  the  Fallopian  tubes,  are  sufficiently  large  to  permit  the  pas- 
sage of  ova,  spermatozoids  and  the  secretion  of  the  membrane  lining 
the  ducts.  They  terminate  at  the  upper  corners  of  the  uterus, 
passing  obliquely  through  the  muscular  wall  to  open  upon  the  en- 
dometrium.  At  their  ovarian  extremities  they  expand  into  the 
pavilions,  slightly  concave  dilatations  lined  with  ciliated  mucous 
membrane;  the  margins  of  the  pavilions  are  fissured  by  irregular 
fringe-like  projections  called  fimbriae ;  one  of  these  is  attached  to 
the  ovary,  forming  the  tubo-ovarian  ligament,  and  anchoring  the 
tube  to  the  ovary.  The  oviducts  or  Fallopian  tubes  are  four  or 
five  inches  long;  from  ^  to  ^  inch  in  diameter,  and  are  com- 
posed of  a  peritoneal,  muscular  and  mucous  coat,  the  last  having 
epithelium  whose  cilise  move  from  the  ovary  toward  the  uterus. 
This  mucous  membrane  is  capable  of  nourishing  by  its  secretion 
an  impregnated  ovum  in  its  first  days  of  life. 

The  male  element  essential  to  reproduction  is  the  spermatozoid , 
an  albuminous  cell  from  ^  to  *fj  of  an  inch  in  length,  consist- 
ing of  a  head,  tail  and  intermediate  segment.  Spermatozoids  are 
endowed  with  motion  sufficiently  rapid  to  enable  them  to  pass 
from  the  vagina  to  the  oviducts  in  a  few  moments.  Their  vital- 
ity persists  when  in  alkaline  media  for  24  or  30  hours;  they  are 
rendered  motionless  by  cold  and  killed  by  acids. 

Impregnation,  the  joining  of  ovum  and  spermatozoid,  may  oc- 
cur in  any  portion  of  the  genital  tract  from  the  uterus  to  the 
ovary.  It  probably  happens  most  frequently  at  the  pavilion  of 
the  oviduct ;  when  the  impregnated  ovum  lodges  in  the  uterus  it 
is  an  entopic,  intra-uterine,  normal  pregnancy;  when  the  impreg- 
nated ovum  is  retained  outside  the  cavity  of  the  uterus,  it  is  an 
extra-uterine  or  ectopic  pregnancy,  which  is  abnormal.  It  should 
be  remembered  that  the  genital  tract,  from  the  cervix  uteri  to  the 
pavilion  of  the  oviduct,  is  essentially  one  musculo-membranous 
tube  whose  epithelial  lining  membrane,  in  any  portion  of  its  extent, 
may  receive  and  nourish  the  impregnated  ovum  in  the  early  stages 
of  its  development,  and  whose  muscular  tissue  finally  expels  the 
ovum  at  maturity.  In  normal  pregnancy  the  fecundated  ovum  is 
soon  passed  onward  into  the  uterus,  whose  muscular  walls  are  es- 


12  MANUAL    OF    PRACTICAL    OBSTETRICS. 

pecially  fitted  to  expel  a  body  of  considerable  size,  like  a  foetus 
at  term,  and  overcome  a  marked  resistance. 

It  will  be  necessary  next  to  consider  the  changes  which  occur 
in  the  ovum  after  fecundation,  and  also  the  accompanying  modi- 
fications in  the  genital  tract  and  in  the  general  organism  of  the 
mother  during  the  growth  of  the  ovum  to  maturity. 

Before  the  contact  of  the  spermatozoid,  the  germinal  vesicle  of 
the  ovum  moves  towards  the  periphery  and  from  the  vesicle  pro- 
jects one  or  more  cells  or  globules,  called  polar  globules,  whose 
function  in  the  production  of  the  new  being  is  unknown.  The 
portion  of  the  germinal  vesicle  remaining  after  the  formation  of 
the  polar  cells  is  known  as  the  female  pronucleus.  The  sperma- 
tozoid penetrating  the  yelk  or  vitellus,  loses  its  tail  and  interme- 
diate portion,  and  the  head  forms  the  male  pronucleus.  After 
the  entrance  of  one  spermatozoid  others  are  excluded  by  the 
formation  of  the  vitelline  or  yelk  membrane,  thus  rendering  the 
production  of  monsters  in  normal  cases  impossible,  by  preventing 
the  joining  of  more  than  one  spermatozoid  with  the  ovum. 

Both  male  and  female  pronuclei  approach  each  other,  joining 
in  a  nucleus,  and  segmentation  or  cleavage  occurs.  This  begins 
in  the  nucleus  which  has  been  formed  by  the  union  of  the  ovum 
and  spermatozoid ;  the  yelk,  or  vitelline  mass  which  surrounds  it, 
shares  in  the  process,  so  that  a  portion  of  the  yelk  accompanies 
each  of  the  first  two  nuclei  formed  by  the  division. 

This  process  is  continued  until  the  ovum  has  become  a  mass 
of  minute  spheres,  the  whole  resembling  a  mulberry,  and  called 
the  muriform,  or  mulberry-like  body  (Fig.  3).  These  spheres  are 
of  various  sizes ;  the  larger  and  more  transparent  compose  the  epi- 
blast,  or  upper  germs;  the  smaller  the  hypoblast,  or  under  germs. 

The  hypoblast  remains  in  the  centre  of  the  ovum,  while  the 
epiblast  surrounds  it.  The  ovum,  at  this  stage,  is  five  or  six  days 
old,  and  usually  passes  from  the  oviduct  to  the  uterus,  where  it 
lodges  in  an  infolding  of  the  endometrium,  which  undergoes  vari- 
ous important  modifications,  fitting  it  to  retain  and  nourish  the 
embryo. 

The  membranes  which  envelope  the  ovum  are  known  as  de- 


OVULATION;  MENSTRUATION;  CONCEPTION;  THE  OVUM.     13 


FIG.  3. 


ciduous,  and  are,  in  the  early  stages  of  development,  three  in 
number.  The  first  is  the  lining  membrane  of  the  uterus,  on 
which  the  ovum  rests, 
formerly  called  Decidua 
Serotina,  now  called 
Placental  Decidua,  be- 
cause it  enters  into  the 
formation  of  the  placen- 
ta. The  lining  decidua 
of  the  uterus  gradually 
extends  over  the  ovum, 
finally  covering  it ;  this 
investing  portion  is  call- 
ed the  Decidua  Reflexa 
or  Ovular  Decidua.  The 
third  deciduous  mem- 
brane covers  the  interior 
of  the  uterus,  and  is  the 
(Fig.  4). 

Returning  to  the  ovum,  we  find  that  after  the  formation  of  the 
Fl(,  mulberry,  or  muriform  body,  a  fissure 

appears  between  the  epiblast  and  hypo- 
blast,  which  separates  them  in  such  a 
manner  as  to  form  a  vesicle  inside  the 
vitelline  membrane,  whose  wall  is  form- 
ed by  epiblast  cells,  with  the  hypoblast 
cells  accumulated  on  a  part  of  its  inter- 
nal surface ;  this  vesicle  is  the  blasto- 
dermic  vesicle.  It  grows  rapidly,  the 
hypoblast  flattening  and  extending  with- 
in the  epiblast. 

A  third  layer  of  cells  is  now  formed, 
probably  from  the  two  others,  called 
the  mesoblast.     From  these  layers  are 
developed  the  various  tissues  and  organs 
THE  DECIDUOUS  MEMBRANES,  of   the    foetus,    as    follows :     from    the 


E.    THE  MURIFORM  BODY. 
Decidua   Vera,    or   Uterine  Decidua 


14  MANUAL   OF   PRACTICAL   OBSTETRICS. 

epiblast  are  formed  the  nervous  system  and  parts  of  the  organs  of 
the  special  senses  :  from  the  hypoblast  are  formed  the  epithelium 
of  the  digestive  and  respiratory  tract,  the  cylindrical  epithelium 
of  the  liver  ducts,  the  pancreas,  thyroid  gland  and  glands  of  the 
alimentary  canal,  and  the  hepatic  and  pancreatic  parenchyma. 
From  the  mesoblast  are  derived  the  muscles,  bones,  connective 
tissue,  arteries,  veins,  lymphatics  and  capillaries  with  the  urinary 
and  generative  organs  (Fig.  5). 

FIG.  5. 


THE  EMBRYONIC  AREA  AND  AXIAL  GROOVE. 

The  epiblast,  mesoblast  and  hypoblast  unite  in  forming  an  em- 
bryonic area  or  Area  Germinativa,  which  is  oval  in  shape;  in  the 
centre  of  this  body  there  appears  a  groove  called  the  axial  or  me- 
dullary groove,  which  becomes  enclosed  by  folds  from  either  side 
forming  a  closed  tube,  the  neural  canal. 


CHAPTER    II. 


THE    EMBRYO. 


THE  embryo  now  begins  to  take  shape,  and  resembles  rudely  a 
boat  with  extremities  of  unequal  size.  The  larger  is  the  cephalic, 
the  smaller  the  caudal  extremity  (Figs.  6  and  7). 


FIG.  6. 


EMBRYO,  SEVEN  OR  EIGHT  WEEKS  OLD. 

The  folding  in  of  the  blastodermic  vesicle,  which  results  in  this 
boat  shape,  destroys  its  spherical  form,  and  it  becomes  constricted 
into  two  parts,  the  smaller  being  embryonic,  the  larger  forming 
the  yelk  membrane,  or  umbilical  vesicle,  which  nourishes  the  em- 
bryo. 

The  embryo  has  not  only  the  membranes  derived  from  the 
uterus,  but  others  which  surround  it,  formed  in  the  process  of  its 
own  development.  These  are  two  in  number,  the  amnion  .and 
chorion.  The  amnion  begins  in  folds  given  off  by  the  mesoblast 
and  epiblast,  finally  joining  to  form  a  complete  sac. 

As  the  embryo  grows,  the  yelk  sac  or  umbilical  vesicle  gradu- 

15 


i6 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


FIG.  7. 


ally  disappears,  and  another  forms  in  its  place,  the  Allantois,  so 
called  because  it  resembles  a  sausage.  This  in  turn  becomes  con- 
stricted, and  forms  an  outside  and  inside  portion,  that  remaining 

within  the  body  of  the  em- 
bryo forming  the  urinary 
bladder ;  that  projecting 
without  forms  an  umbrella- 
like  expansion  which,  with 
layers  from  the  mesoblast 
and  epiblast,  constitute  the 
second  of  the  foetal  mem- 
branes proper,  the  chorion. 
As  growth  proceeds,  the 
blood  vessels  of  the  Allan- 
tois become  so  extensive  as 
to  form  a  part  of  the  abund- 
ant circulation  of  the  villi 
of  the  chorion.  The  allan- 
toid  sac  contains  an  albumi- 
nousfluid,  but  its  chief  func- 
tion is  that  of  bringing 
blood  vessels  to  the  portion  of  the  chorion  forming  the  Placenta. 
As  the  embryo  grows  the  Amnion  forms  two  layers,  the  external 
of  which  joins  the  vitelline  membrane,  and  the  internal  of  which 
covers  the  foetal  surface  of  the  placenta  and  also  the  umbilical  cord 
(Fig.  8). 

Through  the  medium  of  the  amnion  is  formed  the  amniotic 
fluid  or  liquor  Amnii.  This  is  generally  yellowish,  opalescent  in 
color,  faintly  alkaline,  with  a  specific  gravity  from  1002  to  1015. 
It  contains  from  i  to  1.5  per  cent,  of  solids,  which  are  chlorides, 
phosphates,  sulphates  and  lactates  of  sodium,  potassium  and  cal- 
cium, creatin  and  creatinin,  albumin  and  mucosin  and  urea.  The 
weight  of  the  amnial  liquid  is  greater  than  that  of  the  foetus  dur- 
ing half  of  pregnancy,  but  after  that  period  the  foetus  outweighs 
this  fluid.  Its  color  varies  to  a  dark  reddish  brown  in  women 
who  work  in  tobacco,  and  in  cases  where  the  contents  of  the  foetal 


OVUM  Six  WEEKS  OLD, 

In  the  ovular  decidua  showing  three  openings. 


THE    EMBRYO.  17 

intestine  have  been  expressed  into  the  amniotic  sac.  This  fluid 
is  derived  from  the  fcetus  and  from  the  maternal  blood  vessels  and 
those  of  the  umbilical  cord  and  placenta.  The  Amniotic  fluid 

FIG.  8. 


THE  AMNION  AND  ALLANTOIS. 

A,  B,  Transverse  sections  of  the  Embryo.     C,  D,  E,  f,  Longitudinal  sections,     of,  Amnial 

fluid.     /,  Alimentary  canal,    y,  Yelk  sac  or  umbilical  vesicle,     a,  The  Amnion. 

ac,  Amnial  cavity,     a/,  Allantois.     The  embryo  is  back  downwards. 

serves  as  an  elastic  buffer  to  protect  the  foetus  from  violence,  as  a 
dilator  during  labor,  protecting  the  cord  from  pressure,  and  also 
aiding  in  some  degree  in  nourishing  the  foetus.  It  renders  foetal 


i8 


MANUAL   OF   PRACTICAL   OBSTETRICS. 


FIG.  9. 


movements  easy,  and  thus  assists  in  the  development  of  the  foetus, 

as  illustrated  by  deformities  resulting  in  fostal  limbs  when  the 

fluid  is  deficient. 

Between  the  amnion  and  decidua  the  chorion  is  developed ;  it 

is  derived  from  the  vitelline  membrane,  or  Zona  Pellucida,  which 

is  at  first  a  smooth  membrane 

(Fig.    9).     About    the   second 

week  of  pregnancy  this  smooth 

membrane  becomes  covered  by 

tufts  called  villi ;  they  are  at  first 

solid.     About  the  fourth  week, 

blood  vessels  begin  to  penetrate 

the  villi,  and  the  chorion  be- 
comes complete  by  the  joining 

of  the  allantoid  and  an  interme- 
diate layer  of  the  epiblast.   The 

general  hypertrophy  of  the  villi 

which  follows  causes  the  ovum 

to   resemble    a    chestnut    burr 

whose  projections  are   delicate 

and    vascular.      At    the    third 

month,  the  villi  over  the  larger  free  surface  of  the  ovum  atrophy 

and  disappear,  while  the  villi  at  the  attachment  of  the  ovum  to 

the  uterine  wall,  at  the  placental  de- 
cidua, become  larger  and  more 
branched ;  the  development  of  these 
villi  and  that  of  the  placental  decidua 
forms  the  placenta  (Figs.  loand  n). 
This  body  is  distinct  first  at  the 
third  month,  being  complete  at  the 
beginning  of  the  fourth,  or  sixteen 
weeks  of  pregnancy.  It  is  known  as 
the  "after-birth  or  mother-cake" 
and  is  a  fleshy,  flattened  mass,  usu- 
ally six  to  eight  inches  in  diameter, 
VII.LI  (330  diameters).  and  varying  in  thickness  from  over 


VILLI  OF  CHORION  (low  power). 


FIG.  10. 


THE    EMBRYO. 
FIG.    II. 


Villi. 


Placental 
rj     decidua. 


Uterine 
muscle. 


FIG.  12. 


PLACENTAL  VILLI  AND  DECIDUA. 

an  inch  to  one-fifth,  being  thickest  where  the  cord  is  inserted. 
Its  usual  weight  is  eighteen  ounces,  but  it  varies  with  the  weight 
of  the  child.  The  average 
weight  of  the  placenta  to 
that  of  the  child  is  one- 
third  from  the  seventeenth 
to  the  thirty-second  week. 
Between  the  thirty-second 
and  thirty-third  week  the 
placenta  attains  its  acme  of 
weight,  and  remains  from 
one-third  to  one-fifth  the 
weight  of  the  child,  unless 
influenced  by  derangements 
of  the  foetal  circulation, 
until  birth  at  the  fortieth 
week.  After  the  fortieth 

week  the  placenta  seems  to 

.  ,,     •  ,..  PLACENTA,  MEMHRANES  (stripped  upward., 

grow  rapidly  in  multipart, 


20 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


or  with  women  having  large  children,  thus  raising  the  average 
from  one-fifth  to  one-fourth.  The  external  or  uterine  surface  is 
dark  red,  divided  into  many  areas  by  fissures,  and  covered  by  a 
delicate  greyish  membrane,  the  placental  decidua.  The  internal, 
foetal  surface  is  smooth,  a  little  depressed,  yellowish  in  color,  and 
formed  of  the  chorion  and  amnion  ^Fig.  12). 

The  placenta  is  usually  surrounded  by  a  large  vein,  the  circular 

FIG.  13. 


PLACENTAL  AND  UTERINE  VESSELS.        ^ 

a,  Umbilical  cord.    f,f,  Section  of  uterus,     c,  c,  c,  Umbilical  vessels. 
d,  d,  Curling  arteries  of  uterus. 

sinus  at  its  margin.  It  maybe  divided  into  many  lobes  of  irregu- 
lar shapes.  The  point  of  attachment  of  the  placenta  is  usually 
in  the  upper  portion  of  the  uterus,  either  anteriorly  or  posteriorly. 
Examination  of  the  circulation  of  the  placenta  shows  that  the 
enlarged  blood  vessels  of  the  decidua  gradually  lose  their  walls 
until  only  the  endothelial  cells  of  the  lining  membrane  remain, 


THE    EMBRYO. 


21 


forming  large  sinuses  which  empty  themselves  partly  through  sepa- 
rate veins,  and  partly  through  the  large  vein  or  sinus  at  the  border 
of  the  placenta,  which  communicates  with  the  sinuses  in  the  mus- 
cular tissue  of  the  uterus ;  this  may  be  termed  the  uterine  portion 
of  the  placental  blood  system  (Fig.  13). 

The  foetal  blood  system  consists  of  the  villi  and  their  vessels. 
The  longer  villi  fit  loosely  into  the  decidual  sinuses  as  a  finger  may 
be  inserted  into  a  glove  too  large  for  it.  The  shorter  villi  terminate 
in  the  superficial  cellular  strata  of  the  decidua.  It  is  quite  pos- 
sible to  prove  by  the  injection  of  different  colored  fluids  into  the 
uterus  and  placenta,  that  the  blood  vessels  of  each  do  not  directly 
communicate,  as  is  illustrated  by  the  accompanying  (Fig.  14). 

FIG.   14. 


Amnion. 


THK  PLACENTA  AND  UTI.KIS  (injected  while  adherent). 

It  is  very  common  to  find  lime  salts  deposited  in  normal 
placentae  of  children  born  at  term,  forming  greyish  masses  which 
can  be  readily  felt  by  the  finger,  imbedded  in  the  placental 
tissue.  The  areas  into  which  the  uterine  surface  of  the  placenta 
is  divided  are  called  cotyledons;  a  placenta  which  has  several 
supernumerary  cotyledons  connected  with  the  principal  mass  is 


22 


MANUAL   OF    PRACTICAL    OBSTETRICS. 


called  placenta  succenturiata.  The  relation  between  the  mem- 
branes and  the  wall  of  the  uterus  at  term  may  be  well  shown  by 
the  accompanying  (Fig.  15).  It  must  be  remembered  that  the 

FIG.  15. 


Amnion. 


Chorion 


Placental  dec 


Uterine  decidua 
muscle. 


Point  of  separation. 


THE  MEMBRANES.     (Section  through  uterine  wall). 

chorion  itself  has  neither  vessels  nor  nerves  ;  the  villi  grow  only 
at  those  points  where  the  vessels  of  the  allantois  pass  into  them  to 
protrude,  within  the  villi,  into  the  endothelial  sinuses  of  the  de- 
cidua. The  villi  bud  and  subdivide  luxuriantly  in  the  decidua, 
often  containing  a  capillary  loop  of  allantoid  vessels. 

The  placenta  and  foetus  are  connected  by  the  umbilical  cord, 
which  consists  of  blood  vessels  enclosed  in  a  sheath  of 
embryonal  connective  tissue  known  as  Wharton's  jelly.  In 
ligating  the  cord  after  the  birth  of  the  child,  this  jelly  may 
be  pressed  out  from  the  stump  of  cord  left  upon  the  foetus 
by  grasping  the  stump  with  the  thumb  and  index  finger  of  one 
hand  close  to  the  umbilicus,  pressure  being  made  against  the 
child's  abdomen  to  prevent  traction  upon  the  umbilicus.  With 
the  thumb  and  fingers  of  the  other  hand  the  cord  may  be 
grasped  and  the  jelly  pressed  out  by  traction  away  from  the 


THE    EMBRYO. 


23 


FIG. 


child's  body.  The  blood  vessels  are  three  in  number,  two 
arteries  and  one  vein  which  is  one  sixth  longer  than  the  arteries. 
The  arteries  have  especially  strong  walls,  and  although  they  twist 
in  a  spiral  they  very  rarely  become  dilated  into  varicosities;  the 
vein  is  large,  with  a  thin  wall  and  without  valves.  It  comes  from 
the  placenta,  and  winding  about  the  arteries  passes  to  the  foetal 
liver.  Pressure  in  the  vein  is 
greater  than  that  in  the  arteries ; 
the  result  is  a  twist  usually  from 
right  to  left  in  the  cord.  These 
spirals  vary  greatly  in  number, 
from  none  to  forty  or  more,  and 
form  gradually  early  in  pregnan- 
cy when  the  foetus  is  freely  mov- 
able and  can  follow  the  twisting 
of  the  cord.  Later,  the  foetus 
is  too  large  and  heavy  to  rotate 
evenly,  and  the  cord  may  then 
coil  about  some  portion  of  the  foetus  or  open  loops  remain 
(Fig.  16). 

Lumps  of  Wharton's  jelly  which  form  along  the  cord  are 
called  nodes.  In  two-thirds  of  all  cas^s  the  cord  is  inserted  in  the 
placenta  between  the  centre  and  the  margin  :  in  one-fifth  of  the 
cases  it  is  inserted  in  the  centre,  less  often  in  the  margin.  When 
the  umbilical  vessels  pass  between  the  membranes  to  be  inserted 
in  the  placenta  it  is  called  a  velamentous  insertion. 

The  cord  is  derived  from  the  allantois  with  the  umbilical  ves- 
sels and  the  vitelline  vessels.  With  Wharton's  jelly  as  a  padding 
or  mould,  its  covering  is  the  amnion.  It  is,  at  term,  usually  a 
little  longer  than  the  foetus,  over  twenty  inches :  it  is  as  thick  as 
a  man's  little  finger. 


CROSS  SECTION  OF  CORD. 

v,  u.  Umbilical  vein. 
a.  u.  Umbilical  arteries. 


CHAPTER   III. 

THE    FCETUS   AND    ITS    PHYSIOLOGY. 

THE  term  embryo  is  usually  applied  to  the  young  being  before 
the  perfect  formation  of  the  placenta  at  the  fourth  month  ;  after 
this  period  it  is  known  as  the  foetus.  While  the  subject  of 
embryology  requires  separate  consideration,  the  practical  interest 
of  the  obstetrician  is  concerned  so  far  as  the  recognition  of  the 
probable  stage  of  development  reached  by  an  embryo  prematurely 
expelled,  and  the  mode  of  production  of  the  most  frequent 
deformities. 

During  the  first  month  the  dorsal  plates  enclose  the  central 
neural  canal  in  which  are  found  the  rudiments  of  the  nervous 
system.  The  heart  begins  to  beat  at  the  third  week,  and  the 
cavities  of  the  body  are  formed  at  the  end  of  the  fourth  week, 
the  ovum  being  as  large  as  a  pigeon's  egg,  the  embryo  half  an 
inch  long.  During  the  second  month  the  face,  head  and  ear 
develop,  and  hare  lip  and  cleft  palate  may  result  from  failure  ot 
union  in  the  bones  of  the  face  and  head.  The  eyes  appear  like 
black  spots,  the  kidneys  are  formed,  the  fingers  and  toes  are 
webbed,  the  ovum  is  as  large  as  a  hen's  egg,  the  embryo  an  inch 
long,  weighing  one  drachm  ;  the  cord  is  over  an  inch  long. 

At  three  months  ossification  begins,  spina  bifida  resulting 
from  failure  of  ossification  in  the  lumbar  vertebrae.  At  the 
fourth  month  the  foetus  is  six  or  seven  inches  long,  the  genital 
organs  are  distinctly  developed,  down  (lanugo)  forms  on  the 
skin,  meconium  is  in  the  intestine,  the  limbs  move.  Such  a  foe- 
tus may  show  heart-beats  for  some  hours  after  birth ;  but  no 
respiratory  movements  occur. 

When  five  months  advanced,  the  foetus  is  ten  inches  long,  the 
cord  being  twelve  inches  in  length;  hair  is  fully  formed,  and 
vernix  caseosa  is  present.  The  foetal  heart  can  generally  be 
24 


THE    FCETUS    AND    ITS    PHYSIOLOGY.  25 

heard,  and  the  mother  usually  appreciates  foetal  movements.  At 
six  months  the  foetus  weighs  a  little  over  a  pound,  and  presents 
many  of  the  appearances  characteristic  of  a  full-term  foetus.  It 
may  live  several  days,  but  dies  chiefly  because  the  lungs  are  too 
imperfectly  developed  to  admit  of  respiration.  A  few  cases  are 
recorded  where  a  foetus  nearly  seven  months  old  has  survived. 

At  seven  months  the  foetus  weighs  three  or  four  pounds,  the 
eye-lids  are  open,  the  testicles  begin  to  descend,  and  the  nails 
are  almost  formed.  The  child  may  live,  is,  in  other  words, 
viable ;  but  its  vitality  is  feeble.  The  eighth  month  is  marked 
more  by  increase  in  weight  than  by  any  new  developments. 

At  the  ninth  month,  or  at  term,  the  foetus  is  from  nineteen  to 
twenty  inches  long,  weighing  between  six  and  seven  pounds. 
Males  exceed  females  slightly  in  weight. 

There  is  no  one  positive  sign  that  the  foetus  is  at  term.  By 
observing  the  presence  of  a  number  of  characteristics,  the  age  of 
a  fcetus  may  be  approximately  estimated.  Twenty  inches  may 
be  taken  as  an  average  length.  The  body  should  be  plump, 
covered  by  the  cheesy  substance  called  vernix  caseosa,  which  is 
a  secretion  from  the  sebaceous  glands  of  the  foetal  skin;  the  nails 
should  be  firm,  the  cartilages  of  the  nose  and  ear  resisting,  hair 
from  one  to  two  inches  long ;  the  child  moves  and  cries  lustily. 
The  cord  is  inserted  a  little  below  the  middle  of  the  trunk. 
Children  weighing  twenty  and  twenty-two  pounds  have  been 
born,  whose  parents  were  not  monstrosities. 

The  following  convenient  table,  constructed  by  Diihrssen,  will 
assist  in  forming  an  idea  of  the  rate  of  foetal  development : 

At  the  end  of  I  month I  x  I  =    I  cm-  =  f  inch. 

At  the  end  of  2  months 2X2=    4  cm.  =  i|  inches. 

At  the  end  of  3      "  3X3=9  cm.  =  4  inches. 

At  the  end  of  4      "  4  X  4=  16  cm.  —  7^  inches. 

At  the  end  of  5      "  5  X  5  =  25  cm.  =  n^  inches. 

At  the  end  of  6      "  6X5  =  3°  cm-  =  13&  inches. 

At  the  end  of  7      "  7  x  5  =  35  cm.  =  15^  inches. 

At  the  end  of  8      "  8  X  5  =40  cm.  =  17^  inches. 

At  the  end  of  9      "  9  X  5  =  45  cm.  =  20  inches. 

At  the  end  of  i  o    "  10  X  5  =5°  cm.  =  22|  inches. 

2 


26  MANUAL   OF   PRACTICAL   OBSTETRICS. 

To  obtain  the  length  of  the  foetus,  multiply  the  month  of 
pregnancy  (ist,  2d,  etc.)  by  a  co-efficient, — i  for  the  first 
month,  2  for  the  second,  etc.,  up  to  5.  After  the  fifth  month 
the  co-efficient  remains  5.  Thus  at  the  seventh  month  the  foetus 
is  7  x  5  centimetres  long,  35  cm.,  or  15^  inches. 

The  nourishment  of  the  foetus  is  effected  at  first  by  the  granu- 
lar matter  of  the  yelk  or  vitellus.  It  also  acquires  an  albuminous 
coating  in  passing  through  the  oviduct,  which  contributes  to  its 
nutrition ;  so  soon  as  they  are  formed,  the  first  chorial  villi 
absorb  nourishment  from  the  decidua ;  the  umbilical  vesicle  as- 
sists for  a  short  time.  The  amniotic  liquid  probably  contributes 
slightly  to  nourish  the  foetus,  although  its  functions  in  this  re- 
spect are  not  positively  known. 

The  great  source  of  foetal  nourishment  is  the  placenta;  a 
direct  interchange  of  gases  and  fluids  takes  place  when  the  villi 
project  into  the  mother's  blood  by  the  process  known  as  osmo- 
sis, and  this  transfer  of  gases  and  solids  in  solution  has  been 
demonstrated  by  various  substances  which,  when  given  to  the 
mother,  affect  the  foetus. 

There  are  two  foetal  circulations,  the  first  during  the  existence 
of  the  umbilical  vesicle,  the  vitelline  circulation ;  the  second,  the 
placental  circulation.  In  the  former,  the  heart  is  a  tube  giving 
off  two  vessels  at  its  superior,  and  two  at  its  inferior  extremities. 
The  heart's  contraction  forces  blood  through  the  two  superior 
vessels,  the  aortic  arches,  into  the  embryo,  thence  into  the  vitel- 
line arteries,  through  which  it  passes  into  the  vitellus ;  it  is  re- 
turned by  a  sinus  which  surrounds  the  umbilical  vesicle,  and 
passes  through  the  omphalo-mesenteric  veins  to  the  heart  again. 

At  the  beginning  of  the  third  month,  the  placental  circulation 
commences.  The  foetal  heart  is  fitted  for  this  circulation  by  two 
important  modifications ;  one  is  an  oval  opening  between  the 
auricles  called  the  oval  foramen  or  Foramen  Ovale,  also  Botall's 
foramen.  In  addition,  the  Eustachian  valve,  at  the  entrance  of 
the  inferior  vena  cava,  is  so  formed  as  to  turn  the  larger  portion 
of  blood  into  the  left  auricle,  through  the  oval  foramen  and  into 
the  left  ventricle.  Two  additional  ducts  or  blood  vessels  are 


THE    FCETUS   AND    ITS    PHYSIOLOGY.  27 

needed  for  the  circulation,  a  venous  and  arterial  duct.  The 
former,  the  ductus  venosus,  connects  the  umbilical  vein  with  the 
inferior  vena  cava ;  the  latter,  the  ductus  arteriosus,  joins  the 
pulmonary  artery  and  aorta  just  below  the  orifices  of  the  arteries 
of  the  head  and  upper  limbs. 

The  fcetal  circulation  will  be  best  understood  if  we  remember 
that' the  lungs  are  inactive  during  intra-uterine  life;  there  is  need 
for  sufficient  blood  in  the  lungs  to  provide  for  their  growth,  but 
not  for  pulmonary  respiration,  as  the  foetus  respires  through  its 
absorption  of  oxygen  from  the  maternal  blood.  Starting  at  the 
placenta,  we  find  the  purified  and  oxygenated  blood  passing 
through  the  umbilical  vein  at  the  umbilicus.  It  will  be  noticed 
that  an  exception  is  formed  to  the  general  law  that  oxygenated 
blood  is  carried  by  arteries  only.  From  the  umbilical  vein  it 
passes  through  the  venous  duct  to  the  inferior  vena  cava,  where  it 
is  joined  by  the  blood  from  the  lower  portion  of  the  fcetal  body; 
a  little  of  this  blood  goes  to  the  liver,  and  blood  from  the  liver 
is  emptied  into  the  vena  cava.  From  the  vena  cava  the  blood 
passes  into  the  right  auricle,  where  the  Eustachian  valve  turns  the 
stream  out  of  its  usual  course  through  the  oval  foramen  into  the 
left  auricle  ;  thence  it  goes,  as  usual,  into  the  left  ventricle. 

When  the  heart  contracts,  the  blood  is  sent  from  the  left 
ventricle  into  the  aorta,  from  the  right  ventricle  into  the  pul- 
monary artery.  The  blood  from  the  left  ventricle  goes  to 
nourish  the  head  and  arms;  blood  from  the  right  ventricle,  being 
needed  in  the  lungs  in  small  quantity  only,  the  greater  portion 
passes  through  the  arterial  duct  into  the  aorta.  It  will  be  ob- 
served that  venous  blood  is  carried  by  the  arterial  duct  and  ar- 
terial by  the  venous  duct,  a  reversal  of  what  is  usually  the  rule, 
resulting  from  the  inactivity  of  the  fcetal  lungs.  The  aorta  finally 
contains  mixed  blood,  which  passes  partly  to  the  lower  limbs  and 
partly  through  the  umbilical  arteries  to  the  placenta  (Fig.  17). 

The  fcetal  organ  which  receives  the  purest  blood  is  the  liver, 
because  important  nutritive  functions  are  carried  on  in  that 
organ.  The  head,  arms  and  trunk  receive  purer  blood  than  the 
legs,  hence  their  better  development.  As  the  foetus  has  little 


28 


MANUAL    OF    PRACTICAL   OBSTETRICS. 


FIG.  17. — Diagram  of  the 
foetal  circulation.  I,  the 
umbilical  cord,  consisting 
of  the  umbilical  vein  and 
two  umbilical  arteries,  pro- 
ceeding from  the  placenta 
(2) ;  3,  the  umbilical  vein 
dividing  into  three  branch- 
es— two  (4,  4)  to  be  dis- 
tributed to  the  liver,  and 
one  (5)  the  ductus  venosus, 
which  enters  the  inferior 
vena  cava  (6)  ;  7,  the 
portal  vein,  returning  the 
blood  from  the  intestines, 
and  uniting  with  the  right 
hepatic  branch ;  8,  the 
right  auricle — the  course 
of  the  blood  is  denoted  by 
the  arrow  proceeding  from 
8  to  9  ;  9,  the  left  auricle  ; 
10,  the  left  ventricle — the 
blood  following  the  arrow 
to  the  arch  of  the  aorta 
(il),  to  be  distributed 
through  the  branches  given 
off  by  the  arch  to  the  head 
and  upper  extremities;  the 
arrows  (12)  represent  the 
return  of  the  o'.ood  from 
the  head  and  upper  ex- 
tremities, through  the  jug- 
ular and  subclavian  veins, 
to  the  superior  vena  cava 
(14),  to  the  right  auricle 
(8),  and  in  the  course  of 
the  arrow  through  the  right 
ventricle  (15)  to  the  pul- 
monary artery  (16) ;  17, 
the  ductus  arteriosus,  which 
appears  to  be  a  proper 
continuation  of  the  pul- 
monary artery — the  offsets 
at  each  side  are  the  right 
and  left  pulmonary  arteries 
cut  off;  the  ductus  arteri- 
osus joins  the  descending 
aorta  (18,  18),  which  divides  into  the  common  iliacs,  and  these  into  the  in- 
ternal iliacs,  which  become  the  umbilical  arteries  (19),  and  return  the  blood 
along  the  umbilical  cord  to  the  placenta,  and  the  external  iliacs  (20),  which 
are  continued  into  the  lower  extremities.  The  arrows  at  the  termination  of 
these  vessels  mark  the  return  of  the  venous  blood  by  the  veins  to  the  inferior 
cava.  (After  Carpenter.) 


THE    FCETUS   AND    ITS    PHYSIOLOGY.  29 

need  for  powers  of  locomotion,  the  growth  of  these  organs  comes 
after  the  development  of  more  vital  parts.  Foetal  respiration  is 
accomplished  by  the  passage  of  oxygen  from  the  mother's  blood 
to  the  red  blood  corpuscle  of  the  fcetal  blood.  This  results  from 
osmosis,  a  physical  property  of  gases  which  enables  them  to  pass 
through  animal  membranes  under  certain  conditions  which  are 
present  in  the  placenta. 

There  is  abundant  need  for  oxygen  in  the  foetus,  and  its  blood 
often  contains  more  haemoglobin  than  its  mother's.  Whatever 
stops  circulation  in  the  umbilical  cord  kills  the  foetus  by  asphyxia. 
The  temperature  of  the  foetus  is  about  one  degree  higher  than  the 
mother's.  The  metabolic  changes  in  the  fcetal  body  while  in  the 
uterus  are  much  slower  than  those  in  the  mother's,  and  as  it  stores 
up  oxygen  it  often  survives  for  some  time  after  its  connection  with 
the  mother  is  cut  off  by  separation  of  the  placenta.  The  various 
secreting  glands  of  the  fcetal  body  are  formed  and  active  at  term. 
The  great  size  and  activity  of  the  foetal  liver  is  caused,  not  by  ex- 
cessive formation  of  bile,  but  by  important  processes  in  the  form- 
ation of  blood  corpuscles  which  go  on  in  that  organ.  Bile  is 
formed  as  early  as  the  third  month,  and  the  intestines  contain 
meconium,  a  tarry  substance  resembling  burnt  molasses,  composed 
of  bile  and  intestinal  juices,  with  substances  swallowed  from  the 
amniotic  liquid.  While  reflex  motions  have  been  observed  on  ir- 
ritating a  fcetal  limb  through  the  uterine  wall,  conscious  move- 
ment does  not  exist  for  some  time  after  birth.  The  gustatory 
nerve  responds  to  bitter  substances  in  children  born  at  seven  and 
eight  months. 

THE  FCETUS  AT  BIRTH. — At  two  hundred  and  seventy  days  the 
human  foetus  measures  on  an  average  twenty  inches  in  length, 
weighs  from  six  and  one-half  to  seven  and  one-half  pounds,  and  is 
marked  by  the  characteristics  already  mentioned.  The  diameter8 
of  its  head  will  be  considered  in  relation  with  those  of  the  birth 
canal  of  the  mother.  The  diameter  of  its  trunk,  which  is  of  the 
greatest  practical  importance  to  the  obstetrician,  is  the  bis-acromial. 
This  is  measured  from  one  acromian  process  to  the  other,  and  is 
on  the  average  twelve  centimetres  or  four  and  three-fourths  inches 


30  MANUAL   OF   PRACTICAL   OBSTETRICS. 

in  extent ;  it  is  capable,  however,  of  considerable  reduction  by 
pressure  during  labor,  from  the  fact  that  the  foetal  bones  possess 
considerable  elasticity.  The  foetal  lungs  at  this  time  are  capable 
of  inflation,  while  the  other  organs  of  the  fostal  body  have  already 
established  their  various  functions. 

THE  FOZTAL  HEAD. — The  foetal  head  is  of  especial  interest  and 
importance  to  the  obstetrician,  because  it  is  the  largest  portion  of 
the  foetus  and  therefore  is  most  likely  to  occasion  difficulty  in  its 
passage  through  the  birth  canal  of  the  mother.  It  is  composed 
at  birth  of  two  parietal,  two  temporal  and  frontal  and  an  occipi- 
tal bone,  which  are  not  yet  solidly  united.  The  facial  bones  of 
the  foetus  are  more  nearly  united  at  birth  than  are  the  bones  of 
the  skull,  nature  seeming  to  leave  the  latter  imperfectly  joined  to 
favor  the  moulding  of  the  head.  The  spaces  between  these  bones 
are  known  as  sutures ;  they  are  the  sagittal  or  arrow  suture,  extend- 
ing antero-posteriorly  in  the  middle  of  the  cranial  vault ;  the 
fronto-parietal,  extending  at  right  angles  to  the  sagittal  between 
the  frontal  and  the  parietal  bones,  and  the  lambdoid,  separating 
the  two  parietal  bones  from  the  occipital.  Two  spaces  between 
the  bones  of  the  skull  are  found  at  the  junction  of  the  frontal  and 
the  two  parietal  bones,  and  at  the  junction  of  the  two  parietal  with 
the  occipital.  The  former,  the  larger,  is  called  the  anterior  fon- 
tanelle  and  also  the  bregma ;  the  latter  is  known  as  the  smaller  or 
posterior  fontanelle  (Fig.  18).  Other  fontanelles  are  sometimes 
found  between  other  bones  of  the  skull.  These  two  fontanelles 
are  of  special  interest  to  the  obstetrician  because  their  recognition 
assists  greatly  in  diagnosticating  the  position  of  the  foetal  head 
during  labor.  The  anterior  or  greater  remains  unaltered  by  the 
pressure  exercised  upon  the  head  and  always  admits  the  tip  of  the 
examining  finger  during  labor.  It  is  to  be  recognized  by  the 
fact  that  four  bony  lines  or  sutures  extend  from  this  fontanelle. 
The  posterior  or  smaller  fontanelle,  on  the  contrary,  is  often  ob- 
literated by  the  pressure  upon  the  foetal  head  during  labor,  and 
its  site  is  distinguishable  only  from  the  fact  that  three  bony  lines 
can  be  identified  as  extending  from  this  fontanelle  (Fig.  19). 

The  recognition  of  the  anterior  and  posterior  fontanelle  enables 


THE    KKTUS    AND    ITS    PHYSIOLOGY.  31 

the  obstetrician  to  locate  the  frontal  and  occipital  regions  of  the 
head.  The  diameters  of  the  foetal  head  are  measurements  taken 
between  certain  bones  by  which  its  size  is  estimated.  These  di- 
ameters are  those  of  length,  width  and  depth;  there  are  four  di- 
ameters of  length,  the  maximum  or  greatest  extending  from  the 

FIG.  1 8. 


The  anterior,  greater 
fbntanelle. 


The  posterior,  smaller 
fontanelle. 


chin  to  a  point  in  the  sagittal  suture  midway  between  the  fontan- 
elles.  It  measures  thirteen  and  a  half  centimetres,  or  five  and 
one-third  inches.  The  next  diameter  of  length  is  the  occipi to- 
mental,  measured  between  the  point  of  the  chin  and  the  occipital 
protuberance.  It  is  thirteen  centimetres,  or  five  and  one-eighth 
inches.  The  most  important  diameter  of  length,  when  the  me- 
chanism of  labor  is  concerned,  is  the  occipito-frontal,  from  the 
root  of  the  nose  to  the  occipital  protuberance.  It  measures 
twelve  centimetres,  or  four  and  three-fourths  inches ;  a  diameter 
of  length  which  is  frequently  substituted  for  the  preceding  in  the 
mechanism  of  labor  is  the  sub-occipito-bregmatic;  it  is  measured 


MANUAL   OF    PRACTICAL   OBSTETRICS. 
FIG.   ig. 


i.  The  parietal  eminences.     2.  The  lateral  fontanelles. 

from  the  middle  of  the  anterior  fontanelle  to  the  under  surface 

of  the  occipital  protuberance,  nine  and  a  half  centimetres,  or 

three  and  three-fourths  inches  (Fig.  20). 

Measures  in  width  are  two 
in  number — the  bi-parietal 
between  the  protuberances 
of  the  parietal  bones,  nine 
and  five-tenths  centimetres, 
or  three  and  three-fourths 
inches,  and  the  bi-temporal, 
eight  centimetres,  or  three 
and  one-eighth  inches. 

The  measures  of  depth 
are  t.vo  in  number — the 
fronto- mental,  between  the 
forehead  and  the  chin, 
measures  eight  centimetres, 
or  three  and  one-eighth 
inches,  and  the  trachelo- 

bregmatic,  between  the  middle  of  the  greater  fontanelle  and  the 


of.  Occipito-frontal  diameter. 

o  m.  Occipito-mental  diameter. 

JT  m.  Maximum  diameter. 

6  s.  Sub-occipito-bregmatic  diameter. 

t  b.  Trachelo-bregmatic  diameter. 

y  m.  Fronto-mental  diameter. 


THE    FOETUS    AND    ITS    PHYSIOLOGY. 


33 


neck  in  front  of  the  larynx,  nine  and  a  half  centimetres,  or  three 
and  three-fourths  inches ;  the  greatest  circumference  coincides 
with  the  maximum  diameter,  measuring  thirty-seven  centimetres, 
or  fourteen  and  one-half  inches. 


CHAPTER    IV. 

THE   BIRTH   CANAL. 

IT  will  now  be  necessary  to  consider  the  birth  canal  of  the 
mother,  and  to  compare  these  measurements  with  those  of  the 
foetus  just  stated.  At  labor  the  uterus,  sinking  at  first  into  the 
pelvis,  forms  an  irregularly  cylindrical  cavity,  the  axis  of  which  is 
the  line  of  direction  followed  by  a  body  in  passing  through  this 
cavity;  the  lower  elastic  portion  of  the  uterus  is  retained  in  the 
bony  pelvis  during  the  last  weeks  of  pregnancy  and  the  first  hours 
of  labor,  and  its  dimensions  are  practically  thosa  of  the  bony 
canal. 

The  uterus  in  pregnancy  may  be  divided  into  three  portions. 
The  first  is  the  expulsive,  consisting  of  the  strong  interlacing 
muscular  fibres  at  the  fundus,  which  end  in  a  border  or  ring.  The 
second  is  the  tissues  between  this  border  or  ring  and  the  internal 
os,  known  as  the  lower  uterine  segment ;  while  the  third  extends 
from  the  internal  through  the  external  os,  forming  the  cervix. 
The  lower  uterine  segment  is  the  elastic  portion  of  the  uterus,  and 
is  composed  of  fibrous  and  muscular  tissue  capable  of  considerable 
distension  (Fig.  21). 

Before  pregnancy,  it  is  impossible  to  recognize  this  lower  seg- 
ment of  the  uterus,  and  its  length  increases  during  this  period 
till  at  term,  when  it  may  be  demonstrated  between  the  lower 
border  of  the  upper  or  expulsive  uterine  segment,  and  the  internal 
os ;  the  cervix  retains  its  former  length  during  pregnancy  and  labor. 

In  the  early  stages  of  labor,  the  cervix  and  lower  uterine  seg- 
ment are  contained  in  the  bony  pelvis,  but  as  labor  proceeds,  the 
upper  expulsive  segment  of  the  uterus  contracts  and  retracts,  thus 
drawing  the  elastic  or  lower  uterine  segment  just  above  the  brim 
of  the  pelvis. 

The  diameters  of  the  bony  pelvis  are  the  measurements  most 
important  in  studying  the  mechanism  of  labor,  and  determining 
whether  or  not  the  normal  foetus  can  pass  through  the  pelvis. 
34 


THE    BIRTH    CANAL.  35 

The  most  important  region  of  the  bony  pelvis  is  the  entrance  or 


FIG.  21. 


Upper  expulsive  uterine 


C,  K.  Contraction  ring. 
o.  i.  Internal  os. 
o.  *.  External  os. 


THE  BIRTH  CANAL. 
superior  strait ;  this  is  also  known  as  the  pelvic  brim,  its  measure- 


36  MANUAL   OF    PRACTICAL   OBSTETRICS. 

ment  from  the  posterior  surface  of  the  pubic  joint  to  the  projec- 
tion or  promontory  of  the  sacrum  being  eleven  and  one-half  cen- 
timetres, or  four  and  one-half  inches.  This  is  the  most  important 
measurement  in  the  birth  canal,  and  is  known  as  the  true  conju- 
gate, or  antero-posterior  diameter  of  the  brim  (Fig.  22). 

FIG.   22. 


DIAMETERS  OF  PELVIC  BRIM. 

The  diagonal  or  oblique  measurements  at  the  brim  of  the  pelvis 
extend  from  one  sacro-iliac  joint  to  the  ilio-pectineal  eminence  of 
the  opposite  side ;  they  measure  twelve  and  one-half  centimetres,  or 
four  and  three-fourths  inches.  Transversely,  from  side  to  side, 
the  brim  of  the  pelvis  measures  thirteen  and  one-half  centimetres, 
or  five  and  one-third  inches ;  this  last  measurement  is  that  in  the 
bony  pelvis;  in  the  pelvic  canal  of  the  living  patient  the  muscu- 
lar and  other  tissues  reduce  the  transverse  diameter,  making  it  less 
than  the  oblique.  This  reduction  is  largely  effected  by  the  ilio- 
psoas  muscles  of  each  side,  which  may  be  relaxed  by  flexing  the 
thighs  upon  the  body;  hence  during  the  first  stage  of  labor,  when 
delay  occurs  in  the  descent  of  the  head  into  the  pelvic  brim,  it  is 
often  advantageous  to  flex  the  patient's  thighs,  thus  rendering 
these  muscles  relaxed  and  facilitating  the  descent  of  the  present- 
ing part  below  the  brim. 


THE    BIRTH    CANAL. 


37 


The  cavity  of  the  pelvis  is  found  to  measure,  on  an  average, 
twelve  and  one-half  centimetres  in  diameter,  or  four  and  seven- 
tenths  inches.  This  measurement  is  of  interest  because  it  is  suf- 
ficiently great  to  allow  the  head,  when  perfectly  flexed  or  perfectly- 
extended,  or  the  breech  of  the  child,  to  rotate  freely  during  labor. 
The  pelvic  brim  having  been  passed,  there  is  evidently  no  reason 
why  the  mechanism  of  labor  should  be  impeded,  so  far  as  the  di- 
mensions of  the  pelvic  cavity  are  concerned. 

Passing  to  the  outlet  of  the  pelvis  the  average  diameter  is 
eleven  centimetres,  or  little  over  four  inches.  The  most  important 
measurement  of  this  region  is  the  anterior-posterior  diameter, 
from  beneath  the  pubic  joint  to  the  tip  of  the  coccyx.  This  is 

FIG.  23. 


PELVIC  OUTLET. 


increased  during  labor  to  measure  from  thirteen  to  fifteen  centi- 
metres, or  from  five  to  five  and  one-fourth  inches.  The  transverse 
diameters  of  the  pelvic  outlet  measure  four  and  one-third  inches, 
or  eleven  centimetres  (Fig.  23). 

The  birth-canal  of  the  mother,  however,  is  but  partially  de- 
scribed in  a  description  of  the  pelvis ;  but  a  portion  of  the  uterus 
is  contained  in  the  pelvis  at  labor,  and  this  important  organ  and 
also  the  floor  of  the  pelvis  must  be  considered  in  any  study  of  the 
birth  canal.  It  has  been  shown  by  means  of  frozen  sections  and 


MANUAL   OF    PRACTICAL   OBSTETRICS. 


FIG.  24. 


post-mortem  examinations,  as  well  as  by  observations  upon  the 
living  patient,  that  during  labor  the  fundus  of  the  uterus  extends 
forward  above  the  line  of  the  pubic  joint.  The  axis  of  the  birth 

canal  is  that  line  which 
would  be  taken  by  a 
globular  or  cylindrical 
body  moving  through 
this  canal.  Such  a  line 
would  extend  from  the 
fundus  of  the  uterus 
downward  and  back- 
ward until  it  should 
meet  the  posterior  por- 
tion of  the  pelvic  floor; 
it  would  then  be  de- 
1  fleeted  at  nearly  a  right 
angle  upwards  and  for- 
wards, to  emerge  be- 
neath the  pubic  joint 
(Fig.  24). 

It  is  to  be  remembered 
that  the  pelvic  cylinder 
is  so  formed  by  a  com- 
bination of  bony  and 
membranous  tissues, 
that  resistance  and  elas- 
ticity are  counterbal- 
anced, thus  favoring  ro- 
tation of  the  presenting 
body.  During  preg- 
nancy the  pelvic  joints 
share  in  the  general 
hypertrophy  of  this  re- 
gion. The  pubic  joint  becomes  specially  enlarged  and  its  mobility 
is  greatly  increased.  This  may  become,  in  some  cases,  a  source  of 
great  annoyance  to  the  patient  and  may  necessitate  rest  in  bed 


X  Y.  Antero-posttrior  (sacro-pubic)  diameter  of  brim. 
ABC.  Composite  line  representing  axis  of  birth  canal. 


THE   BIRTH   CANAL. 


39 


FIG.  25. 


or  the  application  of  a  strong  bandage.  Ordinarily,  however, 
the  other  joints  of  the  pelvis,  although  enlarged,  do  not  show  in- 
creased mobility. 

A  comparison  of  the  diameters  of  the  foetus  with  those  of  the 
birth  canal  will  serve  to  explain  the  phenomena  of  labor.  It  will 
be  remembered  that  the  maximum  diameter  of  the  foetal  head  is 
greater  than  any  diameter  at  the  brim  of  the  pelvis  in  the  living 
patient.  The  same  is  true  of  the  occipito-mental.  It  is  evident 
then,  that  the  head  must  enter  the  pelvis  in  its  descent  in  such  a 
position  that  neither  the  maximum  or  the  occipito-mental  diam- 
eter shall  be  brought  to  present  to  either  of  the  diameters  of  the 
pelvic  brim.  The  avoidance  of  this  occur- 
rence results  from  the  fact  that  the  foetal 
head  is  placed  upon  the  trunk  as  a  lever 
upon  its  fulcrum.  If  a  foetus  be  held  per- 
pendicularly and  the  head  be  allowed  to 
drop  freely,  it  falls  towards  the  front,  the 
chin  resting  upon  the  breast.  This  then  is 
the  longer  arm  of  the  cranial  lever ;  the 
shorter  arm  being  the  distance  from  the 
centre  of  the  head  to  the  occipital  protub- 
erance (Fig.  25).  The  result  of  this  move- 
ment of  the  head  is  to  substitute  for  either 
of  the  two  long  diameters  mentioned  a 
shorter  one,  thus  in  place  of  the  maximum 
diameter  of  13^4  cm.  or  5^  inches  or  the 
occipito-mental  13  cm.  or  5^  inches,  there 
is  presented  the  occipito-frontal  12  cm.  or 
4^  inches  or  the  sub-occipito-bregmatic  9^ 
cm.  or  3^  inches.  A  comparison  of  these 
last  two  diameters  with  those  of  the  pelvic  brim  will  show  that 
when  the  compression  which  the  mother's  soft  parts  undergo  is 
taken  into  account,  there  is  no  reason  why  the  head  when  flexed, 
with  the  chin  upon  the  breast,  should  not  pass  through  the  pelvis. 
If  the  motion  opposite  to  flexion,  extension,  occurs,  one  of  the 
vertical  diameters  of  the  head  is  substituted  for  one  of  the  two 


A,  C.  Axis  of  foetal  body. 
C.  Fulcrum. 

O,  C.  Short  arm  of  lever. 
C,  F.  Long  arm  of  lever. 


40  MANUAL   OF   PRACTICAL   OBSTETRICS. 

greatest  and  thus  descent  is  possible  ;  it  will  be  noticed,  however, 
that  either  flexion  or  extension  must  be  present,  otherwise  a  large 
diameter  will  be  presented  which  cannot  pass. 

THE  PELVIC  FLOOR. — The  study  of  the  pelvic  floor  is  of  special 
interest  to  the  obstetrician.  It  is  that  portion  of  the  birth  canal 
most  frequently  injured  in  labor  and  most  often  demanding  re- 
pair. From  the  standpoint  of  practical  obstetrics  it  may  be 
regarded  as  composed  of  two  segments:  the  anterior,  upper, 
shorter  segment  and  the  lower,  posterior,  longer  segment.  The 
former  embraces  the  anterior  wall  of  the  vagina  and  the  tissues 
beneath  the  pubic  joint,  while  the  latter  comprises  the  strong 
muscles  and  fascia  attached  to  the  sacrum  and  coccyx.  At  the 
moment  of  labor  the  second  or  sacral  segment  is  stretched 
strongly  downward  and  backward  by  the  advancing  foetus,  while 
the  first  or  pubic  segment  is  pushed  upwards  beneath  the  pubes. 

From  the  standpoint  of  obstetric  anatomy,  the  levator  ani 
muscle  and  the  fascia  and  muscular  slips  attached  to  the  perineal 
body  are  the  most  important  tissues  in  the  pelvic  floor.  These 
tissues  may  be  divided  into  three  portions:  the  pubo-coccygeus, 
embracing  the  muscles  arising  beneath  the  pubic  joint  and  pro- 
longed to  the  sides  of  the  pubes,  with  the  anterior  wall  of  the  vagina 
and  the  urethra;  the  obturato-coccygeus  muscle,  which  arises 
from  the  obturator  fascia  and  sides  of  the  pelvis,  and  the  ischio- 
coccygeus,  which  includes  the  muscular  slips  having  origin  from 
the  sides  of  the  ischium.  The  first  of  these  three  divisions  is 
known  as  the  pubic,  the  remaining  two  as  the  sacral  segment  of 
the  pelvic  floor.  The  importance  of  the  perineal  body  consists 
in  the  fact  that  it  is  the  point  of  blending  and  membranous 
attachment  for  the  interlacing  muscular  fibres  of  the  superficial 
tissues  of  the  pelvic  floor.  While,  from  the  standpoint  of  the 
anatomist,  the  pelvic  floor  requires  minute  analysis  and  descrip- 
tion, the  obstetrician  will  gain  little  by  any  but  a  practical  study 
of  this  region  and  its  functions. 

During  labor  the  presenting  part  descends  in  the  axis  of  the 
pelvis  downward  and  backward  until  the  sacral  segment  of  the 
pelvic  floor  is  reached.  The  resistance  afforded  by  the  muscles 


THE    BIRTH    CANAL.  41 

already  mentioned  as  comprising  this  segment,  with  the  strong 
coccygeal  fascia,  exerts  a  considerable  obstacle  to  the  progress 
of  the  head,  and  forces  it  upward  and  forward  beneath  the  pubic 
joint.  The  anterior  or  pubic  segment  of  the  pelvic  floor  is  lifted 
upward  and  greatly  compressed  beneath  the  pubic  joint  by  the 
presenting  part.  The  movement  of  the  coccyx  upon  the  sacrum 
at  the  sacro-coccygeal  joint  and  the  elasticity  of  the  tissues  ena- 
ble the  sacral  segment  to  move  downward  and  backward.  The 
movements  of  the  two  segments  of  the  pelvic  floor  may  be 
likened  to  those  of  folding  doors  swinging  in  opposite  direc- 
tions. In  the  space  left  between  these  segments,  room  is  af- 
forded for  the  escape  of  the  presenting  part. 

Regarding  the  question  of  injury  to  the  pelvic  floor,  it  is  a 
familiar  fact  that  it  is  not  a  simple  linear  tear  which  results  in 
serious  disability,  but  the  separation  from  their  points  of  attach- 
ment to  the  sides  of  the  pelvis  and  .their  insertions  into  the  peri- 
neal  body  of  the  muscles,  which  have  been  collectively  described 
under  the  heads  of  the  segments  of  the  pelvic  floor;  and  it  is 
also  evident  that  in  the  repair  of  recent  injuries  it  is  not  suf- 
ficient to  simply  bring  the  superficial  parts  in  accurate  apposi- 
tion. Beginning  from  above,  the  laceration  in  the  vagina  should 
be  brought  together  until  the  perinaeum  is  reached.  It  is  well 
then  to  begin  a  second  line  of  sutures  extending  from  the  lower 
end  of  the  tear  in  the  perinaeum  upward  to  meet  the  first.  Ine- 
qualities in  the  tissues  can  then  be  adjusted  and  an  accurate  clo- 
sure be  made.  The  suture  should  be  carried  beneath  the  entire 
surface  of  the  tear,  emerging  and  re-entering,  if  desired,  in  the 
centre  of  the  tear.* 

By  reference  to  the  movements  of  the  segments  of  the  pelvic 
floor,  we  appreciate  the  advantages  of  that  method  of  delivery 
in  head  presentations  which  consists  in  pushing  the  pubic  segment 
upward  and  backward  by  pressing  the  head  up  beneath  the  pubic 
joint  with  the  left  hand,  passed  between  the  mother's  thighs,  while 
the  right,  spread  out  upon  the  sacral  segment  of  the  pelvic  floor, 

*  For  more  explicit  directions  for  closing  such  lacerations,  the  reader  is 
referred  to  the  treatment  of  the  accidents  of  labor. 

->* 


42  MANUAL   OF    PRACTICAL   OBSTETRICS. 

regulates  the  stretching  of  these  parts  by  the  head  as  it  advances, 
estimates  the  elasticity  of  this  segment,  and  finally  allows  it  to 
retract,  between  the  pains,  over  the  head  of  the  child. 

As  the  orifice  of  the  birth  canal  at  the  vulva  becomes  an  oval, 
with  tense  edges,  during  delivery,  it  will  be  seen  that  lateral  in- 
cisions at  the  centre  of  each  side  of  the  oval  will  enable  both 
pubic  and  sacral  segments  to  retract  to  better  advantage.  Such 
a  procedure  is  termed  episiotomy. 


CHAPTER    V. 

THE   MOTHER   IN    PREGNANCY. 

CHANGES  IN  THE  MOTHER  OCCASIONED  BY  PREGNANCY. — These 
may  be  described  as  of  two  kinds :  functional  and  organic.  Under 
the  first  may  be  considered  disturbances  of  digestion,  and  of  the 
functions  of  the  nervous  system,  while  under  the  latter  may  be 
included  the  various  hypertrophies  in  the  tissues  of  the  body,  in- 
cluding the  uterus,  variations  in  the  composition  of  the  blood, 
and  structural  changes  in  the  skin  and  in  the  excretory  organs. 

The  first  and  most  common  functional  change  consists  in  the 
variations  in  appetite  and  digestion  commonly  observed.  There 
is  no  anatomical  reason  for  these  abnormalities,  and  they  must  be 
classed  as  reflex,  temporary  and  functional.  They  consist  of  nau- 
sea, repugnance  to  food,  appetite  for  unusual  articles  of  diet,  ex- 
cessive or  diminished  appetite.  The  result  of  these  functional 
disturbances  is  usually  a  temporary  condition  of  anaemia,  which 
often  disappears  as  pregnancy  advances.  In  many  patients,  a 
full  and  even  ravenous  appetite  after  the  third  month  of  pregnan- 
cy, produces  a  condition  of  plethora.  In  some,  assimilation, 
which  is  ordinarily  defective,  is  greatly  stimulated  by  pregnancy. 

Disturbances  of  the  nervous  system  consist  in  an  increased  sen- 
sibility to  reflexes;  heightened  excitability  of  the  central  and 
peripheral  nervous  system,  manifested  by  melancholia  or  exalta- 
tion, apprehension,  increased  imagination  and,  very  commonly, 
forebodings  of  evil.  The  sympathetic  nervous  system  is  espe- 
cially liable  to  functional  variations,  and  the  balance  ordinarily 
maintained  in  the  organism  seems  to  disappear  on  a  slight  cause 
which  occasions  general  perturbation,  the  action  of  the  heart  and 
respiration  being  especially  affected. 

The  most  important  structural  changes  occur  in  the  genital 
organs.  The  uterus  becomes  twenty  times  heavier  than  before 

43 


44  MANUAL    OF    PRACTICAL    OBSTETRICS. 

pregnancy;  its  surface  about  seventy  times  larger;  its  capacity  sev- 
eral hundred  times  as  great.  Its  muscle  hypertrophies  by  the  de- 
velopment of  embryonic  muscle  nuclei.  Its  walls  are  thinner  than 
in  the  non-pregnant  uterus,  but  elastic  and  resisting.  The  en- 
dometrium  undergoes  corresponding  hypertrophy  in  its  glandular 
elements.  The  entire  genital  tract  shares  in  the  hypertrophy  of 
the  uterus,  in  its  muscular,  elastic  and  epithelial  structures.  The 
neck  of  the  womb  softens,  the  difference  being  very  noticeable  on 
touch.  In  first  pregnancies  the  external  os  is  usually  closed  during 
pregnancy;  in  women  who  have  borne  many  children  it  can  be 
readily  entered  by  the  finger. 

The  hypertrophies  otherwise  observed  are  found  in  certain  por- 
tions of  the  mother's  skeleton,  as  the  inner  table  of  the  skull  and 
about  the  joints.  The  vascular  system  is  marked  by  hypertrophy 
of  the  left  ventricle  and  of  the  muscular  coat  of  the  arteries.  The 
skin  is  altered  by  the  deposit  of  pigment  in  various  portions  of  the 
body,  forming  the  areola  around  the  nipple,  for  example,  and  the 
excretory  organs  undergo  a  general  glandular  hypertrophy,  which 
consists  in  a  multiplication  of  the  cells  of  the  various  organs.  The 
same  change  is  observed  in  the  secretory  organs  of  the  body.  The 
changes  in  the  blood  are  at  first  a  diminution  in  the  red  corpuscles 
and  haemoglobin,  followed  by  a  decided  increase  as  pregnancy 
advances.  The  loss  of  blood  usually  occurring  at  labor  results  in 
temporary  diminution  of  the  amount  of  corpuscles  and  coloring 
matter,  followed  during  the  healthy  puerperal  state  by  an  increase 
to  an  amount  equal  to  or  greater  than  that  found  during  pregnancy. 
As  the  red  corpuscles  and  haemoglobin  diminish,  the  white  cor- 
puscles and  water  increase ;  albumin  diminishes  at  first,  as  does 
fibrin,  but  toward  the  latter  months  of  pregnancy  fibrin  increases 
very  considerably. 

Marked  anaemia  occurring  during  pregnancy  cannot  be  regarded 
as  physiological,  but  is  usually  caused  by  improper  hygienic  sur- 
roundings. Anaemia  after  labor  is  usually  the  result  of  hemorrhage, 
and  occasionally  follows  the  establishment  of  the  function  of  lacta- 
tion; as  a  rule,  however,  when  the  secretion  of  milk  is  well  estab- 
lished, anaemia  should  give  place  to  a  normal  condition  of  the 
blood,  and  very  often  to  slight  plethora. 


CHAPTER    VI. 

THE   DIAGNOSIS   OF   PREGNANCY. 

WHILE  many  conditions  exist  which  may  justify  a  presumptive 
diagnosis  of  pregnancy,  yet  a  certain  diagnosis  of  this  condition 
cannot  be  made  before  the  existence  of  the  foetus  is  appreciable 
by  sight,  hearing,  or  the  tactile  sense.  The  conditions  upon 
which  presumption  may  be  based  are  the  cessation  of  menstrua- 
tion, nausea,  occurring  in  the  early  morning,  abnormal  sensibi- 
lity with  sensations  of  prickling,  stinging,  or  sharp  pains  through 
the  mammary  glands,  with  discoloration  about  the  nipples:  a 
sensation  of  weight  or  fullness  of  the  lower  portion  of  the  abdo- 
men, and  those  ill-defined  sensations  which  cause  the  woman  to 
believe  that  pregnancy  exists.  These  conditions,  however,  may 
all  be  present,  and  yet  the  patient  not  be  pregnant. 

Again,  from  the  standpoint  of  the  physician,  presumptive  evi- 
dence may  be  found  of  pregnancy,  and  yet  the  condition  be 
absent.  Any  cause  which  produces  an  enlargement  of  the  uterus 
and  softening  of  the  neck  and  mouth  of  the  womb  may  give  rise 
to  a  presumption  of  pregnancy,  especially  if  menstruation  is 
absent ;  but  it  must  be  insisted  upon  that  it  is  not  until  the  phy- 
sician can  feel  the  movements  of  the  foetus,  or  see  those  move- 
ments through  the  abdominal  wall  of  the  mother,  or  hear  the 
beating  of  the  foetal  heart,  that  a  positive  diagnosis  of  pregnancy 
can  be  made. 

A  strong  presumption  that  ectopic  or  extra  uterine  pregnancy 
exists  may  be  based  upon  absence  of  menstruation ;  a  tumor  found 
by  examination  near  the  uterus,  but  distinct  from  it:  changes  of 
the  mammary  glands ;  the  fact  that  the  uterus  itself  can  be  de- 
monstrated to  be  but  slightly  enlarged,  and  the  occurrence  of  ir- 
regular attacks  of  hemorrhage.  While  there  is  no  one  symptom  on 

45 


46  MANUAL   OF   PRACTICAL   OBSTETRICS. 

which  a  positive  diagnosis  of  ectopic  pregnancy  can  be  made, 
yet  if  decidual  membrane  can  be  demonstrated  as  discharged 
coincidently  with  hemorrhages,  a  very  strong  presumption  exists, 
especially  if  the  other  symptoms  be  present. 

If  the  physician  be  consulted  by  a  patient  who  has  reason  to 
suppose  herself  in  the  early  months  of  pregnancy,  a  careful  ex- 
amination should  be  made,  and  if  a  strong  presumption  exists, 
this  fact  should  be  stated  to  the  patient.  She  should  be  in- 
structed regarding  the  hygiene  necessary  for  this  period,  and 
informed  that  a  positive  diagnosis  cannot  be  made  for  several 
weeks  or  months.  As  early  in  pregnancy  as  possible,  the  physi- 
cian should  examine  his  patient  thoroughly  to  make  a  positive 
diagnosis  of  pregnancy,  and  also  to  determine  the  presence  or 
absence  of  any  abnormalities  of  the  pelvis  or  birth-canal  of  the 
mother.  A  second  examination  at  seven  or  eight  months  should 
be  made  to  diagnosticate  the  position  of  the  foetus,  and  to 
determine  the  necessity  for  version  or  some  procedure  to  alter  an 
abnormal  position  at  the  occurrence  of  labor. 

When  the  first  examination  takes  place,  it  is  well  to  make  an 
appointment  with  the  patient  to  come  to  the  physician's  office, 
or  that  he  may  call  upon  her  at  her  home.  The  assistance  of  a 
friend  or  nurse  is  often  advantageous  and  agreeable.  The  patient 
should  be  instructed  to  lie  upon  a  bed  or  couch,  clad  so  that  but 
one  thickness  of  linen  will  be  found  covering  the  abdomen  and 
pelvis.  The  physician  should  palpate  the  abdomen  carefully, 
mapping  out  the  enlarged  uterus,  and  auscultate  for  fetal  heart- 
sounds,  being  careful  to  take  sufficient  time  to  recognize  them, 
and  then  measure  the  patient's  pelvis.  All  of  this  can  be  done 
through  one  thickness  of  linen,  if  that  linen  be  not  new  and 
stiff. 

The  pelvic  measurements  which  should  be  invariably  made  are 
but  three  in  number :  they  are,  between  the  anterior  superior 
spines  of  the  ilia,  twenty-six  and  one-half  centimetres,  or,  in  round 
numbers,  ten  inches ;  between  the  crests  of  the  ilia,  twenty-eight 
centimetres,  or  eleven  inches ;  from  beneath  the  spine  of  the  last 
lumbar  vertebra  to  the  middle  of  the  pubes,  eight  inches,  or  twenty 


THE    DIAGNOSIS    OF    PREGNANCY.  47 

and  one-half  centimetres.  This  measurement  is  known  as  the 
external  or  Baudelocque's  conjugate  diameter.  Three  and  one- 
half  inches  or  nine  centimetres  should  be  subtracted  for  the  thick- 
ness of  the  sacrum  and  pubes.  Four  and  one-half  inches,  eleven 
centimetres,  the  remainder,  is  known  as  the  internal  conjugate,  or 
conjugata  vera.  To  make  the  last  measurement,  the  patient  should 
turn  upon  her  side,  her  thighs  flexed,  and  lying  conveniently  with 
her  face  turned  away  from  the  physician.  Should  doubt  exist  as  to 
the  location  of  the  last  lumbar  spine,  visual  inspection  of  the 
back  may  be  made  without  offending  the  patient.  If  the  three 
measurements  given  are  found  to  be  normal,  the  probability  that 
any  deformity  in  the  bony  birth-canal  exists  sufficiently  great  to 
complicate  labor,  is  very  slight.  The  distance  between  the  tro- 
chanters  may  also  be  conveniently  measured ;  it  is  thirty-two  cen- 
timetres, or  thirteen  inches  (Fig.  26). 

At  the  second  examination  the  position  of  the  foetus  should  be 
carefully  outlined  by  palpation,  and  auscultation  be  repeated. 
Palpation  is  best  performed  by  standing  with  the  face  towards 
the  patient's  feet,  the  extended  hands  resting  lightly  upon  the 
patient's  abdomen.  By  gentle  pressure  simultaneously  with  both 
hands,  a  sense  of  resistance  can  usually  be  readily  appreciated, 
which  will  indicate  the  location  of  the  child's  back.  The  fin- 
ger tips  of  each  hand  should  then  be  placed  in  line  parallel  with 
Poupart's  ligament  on  each  side;  by  gentle,  but  deep  pressure 
downwards  and  inward,  the  presenting  part  is  felt.  If  now  both 
hands  be  moved  together  either  to  the  right  or  left,  the  head  or 
breech  will  be  felt  to  move  with  the  hands.  In  women  whose 
tissues  are  relaxed,  the  position  of  the  head,  in  extension  or 
flexion,  can  often  be  determined.  The  site  of  the  placenta  can 
occasionally  be  found  by  palpation,  when  it  is  situated  upon  the 
anterior  wall  of  the  uterus.  In  multiple  pregnancies,  the  ob- 
server must  outline  three  large  foetal  parts  or  extremities  before  a 
diagnosis  can  be  made  by  palpation.  Two  distinct  foetal  hearts 
must  be  heard  by  auscultation  to  make  a  diagnosis  positive. 

Information  of  value  may  also  be  gained  by  the  obstetrician 
if,  during  palpation,  he  will  notice  the  muscular  development 


48 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


and  consistence  of  the  abdominal  walls,  as  their  contraction  fur- 
nishes an  important  accessory  force  in  labor.  The  bladder 
should  be  invariably  emptied  before  palpation,  as  a  full  bladder 


FIG.  26. 


A  A'.  Distance  between  crests  of  ilia. 

B  B'.  Distance  between  anterior  superior  spinous  processes  of  ilia. 

C  C'.  Distance  between  trochanters  of  femora. 

renders  an  accurate  examination  impossible.     During  palpation 
foetal  movements  are  appreciated  by  the  fingers,  and  often  seen 


THE    DIAGNOSIS   OF   PREGNANCY.  49 

in  cases  where  the  foetus  moves  vigorously.  In  hysterical  or 
maniacal  patients  a  slight  degree  of  anaesthesia  may  be  required 
for  a  satisfactory  examination.  On  auscultation,  in  head  present- 
ations the  heart  sounds  are  heard  below  the  umbilicus,  on  the  left 
or  right  side ;  in  breech  presentations  above  the  umbilicus ;  in 
transverse  positions  near  the  pubes.  A  loud,  rushing  sound,  syn- 
chronous with  the  mother's  pulse,  is  the  uterine  souffle,  caused  by 
the  blood  in  the  enlarged  uterine  sinuses.  A  faint,  rapid  hissing 
sound  is  the  umbilical  souffle,  a  murmur  in  the  cord  which  is 
twisted  about  the  foetus.  Gas  may  be  heard  to  crackle  in  the 
mother's  intestines. 

In  doubtful  cases,  percussion  must  be  resorted  to  in  distin- 
guishing the  pregnant  uterus  from  ovarian  tumors  or  ascites.  It 
will  be  remembered  that  the  pregnant  uterus  forms  a  solid  or 
semi-solid  tumor  occupying  the  centre  of  the  abdomen,  sur- 
rounded on  three  sides  by  intestines  which  usually  give  a  reso- 
nant note  on  percussion.  If  the  patient  be  turned  upon  either 
side,  the  relative  position  of  the  dull  and  resonant  note  changes 
but  slightly,  while  in  ascites  the  gravitation  of  fluid  to  the  sides 
alters  the  location  of  dullness.  An  ovarian  cyst  can  be  distin- 
guished in  its  early  growth  as  located  more  upon  one  side  of  the 
pelvis.  A  uterus  enlarged  by  fibroids  which  are  undergoing  a 
cystic  and  often  malignant  degeneration  may  give  the  same  phy- 
cal  signs  as  the  pregnant  uterus. 

Percussion  of  the  pregnant  abdomen  should  also  give  informa- 
tion regarding  the  size  of  the  uterus,  and  hence  the  period  qf 
pregnancy.  In  general,  we  may  say  that  the  uterus  can  first  be 
felt  above  the  pubes  at  the  fourth  month.  In  the  sixth  month  it 
is  at  the  umbilicus ;  at  the  end  of  pregnancy,  a  hand's  breadth 
above  the  umbilicus.  We  add  a  table,  constructed  by  Duhrssen, 
showing  the  size  of  the  uterus  at  the  different  months  of  pregnancy : 

In  the  1st  month  the  uterus  is  slightly  enlarged. 
In  the  ad  month  the  uterus  is  as  large  as  a  goose  egg. 
In  the  3d  month  the  uterus  is  as  large  as  a  child's  head. 
In  the  4th  month  the  uterus  is  as  large  as  a  man's  head,  and  can  be  felt  by 
external  examination  above  the  symphysis  pubis. 
3 


50  MANUAL    OF    PRACTICAL    OBSTETRICS. 

In  the  5th  month  the  uterus  is  half-way  between  the  umbilicus  and  the 
symphysis. 

In  the  6th  month  it  is  at  the  umbilicus. 

In  the  7  th  month  it  is  two  fingers'  breadth  above  the  umbilicus. 

In  the  8th  month  it  is  the  width  of  the  hand  above  the  umbilicus. 

In  the  Qth  month  it  is  at  the  xyphoid  process. 

In  the  loth  month  it  is  again  the  width  of  the  hand  above  the  umbilicus. 

If  anything  abnormal  be  detected  in  the  position  of  the  foetus 
indicating  disproportion  between  the  child  and  the  mother's  pelvis, 
an  internal  examination  should  be  made  (Fig.  27).  To  measure 

FIG.  27. 


INTERNAL  MEASUREMENT  OF  THE  ANTERO-POSTERIOR  DIAMETER  OF 
PELVIC  BRIM. 

the  antero -posterior  diameter  of  the  pelvic  brim  (conjugata  vera, 
true  conjugate)  the  patient  is  placed  on  her  back  at  the  edge  of  a 
bed  or  table,  her  thighs  flexed.  The  bladder  and  rectum  being 
empty,  the  physician  introduces  the  index  and  second  fingers  of 


THE   DIAGNOSIS   OF   PREGNANCY.  51 

one  hand,  pushing  the  cervix  aside,  and  touching  the  promontory 
of  the  sacrum  with  the  second  finger.  The  edge  of  the  hand  is 
raised  against  the  sub-pubic  ligament,  and  with  the  nail  of  a  finger 
of  the  other  hand  the  point  where  the  edge  of  the  pubes  presses 
is  marked  upon  the  examining  hand,  which  is  then  withdrawn, 
and  the  distance  from  the  tip  of  the  second  finger  to  the  point 
marked  is  measured  by  tape  line  or  pelvimeter.  Two  centimetres, 
or  three-fourths  of  an  inch,  is  deducted  for  the  thickness  of  the 
pubes.  The  measurement  first  obtained  is  thirteen  centimetres, 
less  two,  is  eleven  centimetres,  or  four  and  a  half  inches.  It  is 
well  to  follow  the  sacral  curve  upwards  with  the  examining  finger, 
to  avoid  mistaking  the  projection  of  other  sacral  vertebrae  for  the 
promontory. 

If  the  maternal  parts  be  relaxed  and  labor  be  approaching,  it 
is  well  to  attempt  to  estimate  the  proportionate  size  of  the  foetus 
and  the  pelvis  by  pressing  the  presenting  part  gently  downward 

FIG.  28. 


into  the  pelvis  while  its  progress  is  recognized  by  an  internal  ex- 
amination. It  cannot  be  too  strongly  urged  that  it  is  the  duty  of 
the  physician  to  make  preliminary  examinations  in  every  case, 
as  experience  has  shown  us  that  they  can  be  so  conducted  as  to 
give  the  patient  no  inconvenience,  while  affording  valuable  data 
for  the  conduct  of  labor. 

The  pelvimeter  which  we  commonly  employ  is  indexed  in 
centimetres  and  inches,  and  can  be  conveniently  taken  apart 
and  carried  in  the  pocket  (Fig.  28). 


52  MANUAL   OF    PRACTICAL   OBSTETRICS. 

In  making  a  vaginal  examination  to  determine  the  existence  of 
early  pregnancy,  in  addition  to  the  softened  condition  of  the  os 
and  cervix,  the  lower  uterine  segment  may  be  distinguished  in 
many  cases.  The  finger  may  detect  softened,  elastic  tissue  just 
above  the  cervix,  the  body  of  the  uterus  swelling  out  above  it  as 
the  body  of  a  jug  bulges  sharply  above  its  neck.  It  is  often  ne- 
cessary to  examine  with  one  finger  in  the  vagina  and  another  in 
the  rectum,  to  obtain  this  sign  distinctly.  This  is  Hegar's  sign 
and  can  be  found  at  the  third  or  fourth  month. 

Cases  will  come  to  the  notice  of  practitioners  of  experience 
where  the  reputation  and  happiness  of  the  patient  may  depend 
upon  the  physician's  diagnosis.  In  such  cases  the  greatest  cau- 
tion must  be  exercised ;  the  physician  must  give  no  statement 
which  can  be  misconstrued.  He  will  do  well  to  satisfy  himself 
with  a  statement  of  what  he  actually  finds  after  a  careful  examina- 
tion. He  may  then  state  that  such  symptoms  and  conditions 
sometimes  accompany  pregnancy,  but  that  an  absolute  diagnosis 
at  the  moment  of  speaking  is  impossible. 


CHAPTER  VII. 

THE   HYGIENE   OF   PREGNANCY. 

THE  care  of  the  pregnant  woman  should  begin  from  the  time 
when  her  condition  is  first  suspected.  Fortunately  for  her,  that 
which  is  best  for  her,  if  pregnant,  is  also  proper  care  if  she  be 
not  pregnant,  but  suffering  from  any  condition  which  may  give 
rise  to  a  supposition  of  pregnancy.  A  subject  of  perhaps  the  first 
importance  at  this  time  is  the  patient's  dress.  It  is  best  to  lay 
aside  corsets,  or  if  the  patient  will  not  do  this,  to  wear  such  as 
have  been  carefully  made  to  fit  the  body  loosely.  Better  than 
corsets  are  waists  of  various  sorts,  to  which  skirts  can  be  buttoned, 
and  which  are  so  devised  as  to  avoid  injurious  pressure.  The 
important  point  is  to  remove  from  the  abdomen  the  pressure  of  the 
patient's  clothing,  and  the  benefit  to  be  derived  from  this  will  not 
be  realized  until  a  radical  change  in  the  patient's  dress  is  made. 
If  skirts  are  not  attached  to  a  properly  constructed  waist,  they 
should  be  supported  from  the  shoulders  by  suspenders. 

Next  to  the  patient's  skin  should  be  worn  woolen  of  fine  qual- 
ity and  light  weight.  The  so  called  combination  suits,  in  which 
shirt  and  drawers  are  virtually  one  piece,  are  excellent  in  this  con- 
dition. Woolen  or  silk  stockings  should  be  worn,  and,  if  possible, 
supported  without  encircling  garters.  Shoes  and  slippers  should 
be  sufficiently  easy  to  avoid  pressure,  and  if  warm  clothing  is 
necessary,  dresses  and  wraps  may  be  altered  or  made  so  as  to  keep 
the  patient  thoroughly  warm  while  distributing  the  weight  of  the 
garments  as  evenly  as  possible,  and  suspending  them  from  the 
shoulders.  Many  of  the  pressure  symptoms  from  which  patients 
suffer  during  the  early  months  of  pregnancy  are  more  relieved  by 
the  adoption  of  suitable  dress  than  by  any  other  measure. 

The  first  symptom  for  which  the  physician  will  commonly  be 
asked  to  prescribe  is  nausea  and  vomiting.  The  patient  should 

53 


54  MANUAL    OF    PRACTICAL    OBSTETRICS. 

be  informed  that  these  symptoms  are  almost  the  invariable  accom- 
paniments of  her  condition,  and  that  they  will  grow  better  as 
time  goes  on.  Drugs  should  be  used  as  sparingly  as  possible,  and 
the  case  can  often  be  palliated  by  simple  precautions  regarding 
the  taking  of  food.  Many  patients  get  on  comfortably  by  taking 
a  breakfast  in  bed.  Others  are  helped  by  a  cup  of  soup,  or  tea, 
or  coffee,  hot  water,  an  effervescing  drink,  champagne,  brandy- 
and-soda,  while  severe  cases  require  confinement  in  bed  and  the 
most  careful  feeding,  nutritive  enemata  being  especially  useful. 
Slight  dilatation  of  the  cervix  relieves  a  considerable  number  of 
cases  of  the  vomiting  of  pregnancy.  The  finger  is  the  best  di- 
lator, or  a  hard  rubber  dilator  of  about  the  same  size.  Where 
endocervicitis  is  present  alterative  applications  are  indicated.  A 
strong  solution  of  silver  nitrate,  gr.  20  to  the  ^,  has  been  often 
advantageous.  Creolin  or  iodine  is  also  useful.  Such  applications 
should  be  followed  by  a  glycerine  tampon. 

In  general,  it  may  be  stated  that  every  cause  of  irritation  about 
the  womb  should  be  removed,  and  this,  in  many  cases,  will  greatly 
diminish  the  nausea  and  vomiting.  It  is  especially  necessary  to 
see  that 'the  patient  does  not  suffer  from  constipation,  and  her  un- 
pleasant sensations  will  often  disappear  when  this  is  remedied. 

Should  these  measures,  however,  not  be  sufficient,  and  the  patient 
become  anaemic,  the  aid  of  drugs  should  be  sought.  Oxalate  of 
cerium,  or  valerianate  of  cerium,  sub-nitrate  -of  bismuth,  pan- 
creatin,  pepsin,  and  ingluvin  may  also  be  tried.  Two  and  a  half, 
or  five  grains,  of  one  of  the  compounds  of  cerium,  frequently 
repeated,  often  gives  good  results.  Bismuth  may  be  used  in  these, 
and  larger  doses.  The  digestive  ferments  may  be  given  with 
food,  or  pre-digested  food  may  be  employed.  Should  this  not  be 
sufficient,  one  drop  of  tincture  of  iodine  may  be  given,  or  creo- 
sote, or  carbolic  acid.  Cocaine,  or  wine  of  cocoa,  will  often  be 
successful  when  all  else  has  failed.  Fowler's  Solution  and  tincture 
of  nux  vomica  may  be  given  in  doses  of  one  drop  of  each.  Num- 
berless other  remedies  have  been  employed,  and  each  case  must 
be  studied  and  treated  upon  its  own  merits.  It  must  be  remem- 
bered, however,  that  the  local  treatment  of  the  uterus,  and  the 


THE   HYGIENE   OF   PREGNANCY.  55 

patient  and  skilful  use  of  small  quantities  of  suitable  nourishment, 
with  the  digestive  ferments,  furnishes  the  most  rational- method  of 
treating  these  complications.  If  the  trouble  persists,  the  physi- 
cian should  assure  himself  that  the  uterus  is  not  dislocated,  espe- 
cially by  some  backward  displacement.  It  will  often  be  possible, 
by  using  finely  carded  wool  or  jute  in  the  form  of  antisepticized 
tampons,  to  restore  the  uterus  to  its  proper  position,  and  relieve 
the  patient's  symptoms.  In  cases  of  obstinate  vomiting  in  preg- 
nancy, every  remedy  should  be  tried  which  offers  the  slightest 
prospect  of  success.  Among  those  recently  employed  is  menthol, 
which  may  be  given  in  doses  of  from  one  to  five  grains. 

The  question  of  the  interruption  of  pregnancy  will  depend 
upon  the  presence  or  absence  of  dangerous  anaemia  in  the  mother. 
As  our  study  of  the  blood  progresses,  we  shall  undoubtedly  be 
able  to  recognize  conditions  dangerous  to  mother  and  child  alike, 
by  microscopic  examination  of  the  maternal  blood ;  at  present, 
however,  the  general  rule  may  be  stated  that  whenever  the  mother 
is  threatened  with  dangerous  anaemia,  pregnancy  should  be  in- 
terrupted at  once.  It  may  be  possible,  after  the  uterus  has  been 
emptied,  to  cure  an  endometritis,  or  remedy  some  other  condition 
which  has  caused  the  patient's  suffering.  A  repeated  pregnancy 
would  then  result  successfully.  In  replacing  a  retroverted  preg- 
nant uterus,  it  will  be  well  to  hold  it  in  position  by  some  device 
other  than  a  stiff  pessary.  Tampons  such  as  have  been  already 
mentioned  may  be  covered  with  ointment  of  equal  parts  of  lanolin 
and  cosmoline,  to  which  is  added  powdered  boracic  acid,  ten 
grains  to  the  ounce.  In  hospital  practice,  an  ointment  of  balsam 
of  Peru,  cosmoline,  and  iodoform  may  be  used  to  advantage. 
Warm  douches  may  be  very  cautiously  taken  if  there  be  extensive 
irritation  about  the  uterus,  and  if  the  douches  can  be  administered 
by  a  thoroughly  competent  and  careful  person. 

Regarding  the  further  hygiene  of  pregnancy,  it  may  be  stated 
that  moderation  is  the  golden  rule.  The  patient's  usual  tastes  in 
the  matter  of  food  and  drink  should  be  consulted  and  continued. 
She  will  do  well  to  avoid  fatigue,  especially  standing  and  walking 
for  long  periods.  There  should  be  an  abundance  of  sleep,  and 


56  MANUAL   OF    PRACTICAL   OBSTETRICS. 

an  abundance  of  fresh  air.  Lukewarm  baths  should  be  taken 
daily,  or  if  preferred,  a  sponge-bath  of  moderately  cold  water. 
She  should  avoid  long  drives  over  rough  roads,  but  should  fre- 
quently take  drives  of  moderate  length  and  over  smooth  roads. 
Seasickness  should  be  avoided,  and  any  excitement  or  over-strain. 
Very  hot  churches  and  theatres,  and  crowds  of  any  sort  should  be 
shunned.  At  the  same  time,  every  care  must  be  taken  to  make 
the  patient's  life  during  this  period  one  of  interest  and  pleasure. 
Her  natural  forebodings  should  be  met  by  kind  encouragement, 
and  books  and  surroundings  which  furnish  healthful  diversion  may 
be  amply  supplied.  There  is  sufficient  evidence  that  the  mother's 
emotions  influence  the  child  powerfully  to  make  it  necessary  for 
her  to  avoid  fright,  or  an  outburst  of  any  violent  emotion.  It 
should  be  remembered  that  the  teeth  are  especially  liable  to  de- 
teriorate during  this  period,  and  the  services  of  a  dentist  may  be 
sought  early  in  pregnancy.  The  patient  should  be  urged  to  take 
moderate  exercise  in  the  open  air.  Her  diet  should  be  of  the 
most  easily  digested  and  nutritious  articles  of  food.  If  the  patient 
be  found  to  be  lapsing  into  a  condition  of  mal-nutrition,  arsenic, 
iron,  cod-liver  oil  with  hypophosphites,  malt  and  meat  extracts 
may  be  persistently  given.  Koumyss,  Matzoon,  and  Mellin's 
Food  will  be  found  useful  in  such  cases. 


CHAPTER   VIII. 

THE   ATTITUDE    AND   LOCATION    OF   THE   FCETUS ;      THE   DURATION 
OF  PREGNANCY. 

AT  five  or  six  months  of  pregnancy  the  foetus  begins  to  as- 
sume a  definite  position  in  the  uterus,  and  can  be  recognized 
as  having  a  definite  relation  in  situation  to  the  mother.  By  a 
natural  law  of  accommodation,  an  ovoidal  body  contained 
in  a  cylinder  naturally  turns  its  long  axis  parallel  to  that  of 
the  cylinder.  This  is  exemplified  in  the  fact  that  as  the  foetus 
grows,  it  assumes  a  position  which,  in  a  majority  of  cases, 
brings  the  head  to  present  at  the  brim  of  the  pelvis,  the  breech 
and  feet  occupying  the  fundus  of  the  uterus.  The  ovoidal  shape 
of  the  foetus  is  the  result  of  a  condition  of  flexion  which  approxi- 
mates the  limbs  and  head  to  the  trunk.  During  the  early  months 
of  pregnancy  the  specific  gravity  of  the  amnial  liquid  is  so  great 
that  the  foetus  floats  readily  about,  assuming  no  definite  position ; 
but  as  it  increases  in  size,  its  specific  gravity  exceeds  that  of  the 
amnial  liquid,  and  hence  the  heaviest  portion  of  the  foetus  tends 
to  sink  lowest  in  the  uterus,  and  this  fact,  together  with  the  law  of 
accommodation  already  mentioned,  results  in  the  attitude  and  lo- 
cation of  the  foetus.  In  obstetric  phraseology  these  facts  are  de- 
scribed under  the  head  of  (Fig.  29) 

POSITION  AND  PRESENTATION. — By  position  is  meant  the  rela- 
tion which  a  definite  portion  of  the  foetal  body  bears  to  a  defi- 
nite portion  of  the  birth-canal  of  the  mother.  By  presentation 
is  meant  that  portion  of  the  foetus  which  descends  lowest  in  the 
birth-canal,  and  which  comes  first  to  the  notice  of  the  obstetri- 
cian on  examination.  As  we  have  said,  ordinarily  the  head  of 
the  foetus  sinks  lowest,  and  hence  presents  most  frequently.  The 
majority  of  presentations,  then,  are  head  presentations.  From 
the  fact  that  the  attitude  of  the  foetus  is  that  of  flexion,  it  results 

57 


58  MANUAL    OF    PRACTICAL    OBSTETRICS. 

that  the  top  of  the  head  or  vertex  is  the  portion  of  the  cranium 
which  is  most  frequently  lowest,  and  hence  presents.  Thus  it 
happens  that  the  majority  of  head  presentations  are  vertex  pre- 
sentations. Should  the  attitude  of  flexion  of  the  head  not  exist, 
but  should  the  head  have  become  extended,  the  face  of  the  foetus 
will  be  lovvest,  and  hence,  while  the  head  will  continue  to  pre- 

FIG.  29. 


THE  USUAL  ATTITUDE  AND  LOCATION  OF  THE  FCETUS. 

sent,  the  face  instead  of  the  vertex  will  be  the  portion  of  the 
head  sinking  lowest  into  the  pelvis. 

On  the  other  hand,  the  child  may  present  by  the  lower  ex- 
tremity of  the  trunk  or  breech,  and  thus  the  long  axis  of  the 
fcetal  ovoid  be  brought  to  correspond  with  that  of  the  cylindrical 
birth-canal  of  the  mother.  Occasionally,  through  some  failure 
in  the  law  of  accommodation,  the  foetus  at  the  moment  of  labor 
becomes  turned  transversely  across  the  birth-canal,  and  then  a 


THE   ATTITUDE   AND   LOCATION   OF   THE    FCETUS.  59 

transverse  position  results.  The  efforts  of  the  uterus  to  expel  the 
child  thus  turned  across  the  birth-canal  result  in  bending  the  head 
upon  the  trunk  with  a  lateral  flexion,  the  shoulder  of  the  child 
sinking  downward,  and  finally  presenting  in  the  birth-canal. 

If  we  enumerate  the  presentations  which  may  occur,  we  shall 
find  five :  the  vertex,  the  face,  the  breech,  the  right  and  the  left 
shoulder.  If  we  consider  the  situation  which  any  of  these  pre- 
senting portions  may  occupy  in  the  mother's  pelvis,  we  shall  have 
the  positions  and  presentations  grouped  together. 

It  is  of  the  utmost  importance  that,  in  studying  obstetric 
cases,  the  obstetrician  remembers  the  simple  fact  that  the  mother's 
pelvis  has  two  sides,  the  right  and  the  left.  If  the  bony  pelvis 
be  examined,  it  will  be  seen  that  the  points  projecting  furthest 
toward  the  centre  of  the  pelvis  from  each  side  are  the  spines  of 
the  ischia;  extending  obliquely  upward  and  outward  from  these 
points  there  will  be  seen  a  slight  elevation  or  ridge  on  the  bony 
surface  of  the  wall  of  the  pelvis.  This  slight  ridge,  like  a  water- 
shed, divides  each  side  of  the  pelvis  into  an  anterior  and  poste- 
rior half.  The  pelvis  may  then  be  said  to  have  a  left  anterior 
compartment  and  a  right  anterior  compartment,  a  left  posterior 
compartment  and  a  right  posterior  compartment.  It  only  remains 
to  locate  the  foetus  in  one  of  these  four  compartments  to  com- 
plete what  is  technically  described  as  a  presentation  and  posi- 
tion (Fig.  30). 

It  must  be  remembered,  however,  that  more  important  than 
the  especial  compartment  in  the  pelvis  occupied  by  the  present- 
ing part  is  the  question  as  to  which  side  of  the  abdomen  the 
back  of  the  foetus  occupies.  In  fact,  the  more  rational  and 
modern  view  makes  but  two  positions :  If  the  back  of  the  child 
be  toward  the  left  side  of  the  mother's  pelvis,  it  is  the  first  posi- 
tion ;  if  the  back  of  the  child  be  toward  the  right  side  of  the 
mother's  pelvis,  it  is  the  second  position.  When  the  mechanism 
of  labor  is  considered,  it  will  readily  be  seen  how  this  simple 
division  of  positions  accounts  for  the  phenomena  of  labor.  In 
the  majority  of  cases  the  back  of  the  child  lies  upon  the  left  side 
of  the  mother's  abdomen,  the  vertex  presenting  at  the  entrance 


6o 


MANUAL    OF    PRACTICAL   OBSTETRICS. 


FIG.  30. 


to  the  pelvis,  and  turned  in  its  left  anterior  compartment.  The 
resulting  position  and  presentation  is  a  left  occipito-anterior, 
and  this  will  be  found  in  more  than  three-fourths  of  all  cases. 

THE  DURATION  OF  PREGNANCY  is  usually  two  hundred  and 
eighty  days.  Instances  where  pregnancy  is  prolonged  for  ten 

months  and  more  are  not  rare. 
The  cause  for  the  termination 
of  pregnancy  has  not  been 
clearly  demonstrated ;  but  it 
is  most  probably  the  fact  that 
the  foetus  can  no  longer  be 
adequately  nourished  by  the 
mother.  The  accumulation  in 
the  mother's  blood  of  irritat- 
ing compounds  derived  from 
the  processes  of  foetal  nourish- 
ment causes  an  increased  ex- 
citability to  reflex  stimuli.  As 
the  foetus  grows,  its  move- 
ments become  more  vigorous, 
until  the  uterus  is  roused  to 
contraction,  and  labor  results. 
Rhythmic  contractions  of  the 
uterus  continue  during  preg- 
nancy, and  furnish  a  sign  of  pregnancy.  They  assist  in  bringing 
the  long  axis  of  the  foetus  to  coincide  with  that  of  the  uterus. 

In  estimating  the  duration  of  pregnancy  it  is  best  to  avoid  fix- 
ing an  especial  date,  especially  with  primiparse.  From  ten  days 
to  two  weeks'  variation  from  a  calculated  date  is  not  unusual. 
It  is  customary  to  reckon  from  the  last  day  of  menstruation,  and 
a  simple  rule  of  calculation  may  be  stated  as  follows : 

Count  backward  three  months  from  the  last  day  of  menstrua- 
tion, and  add  one  year  and  seven  days  to  the  date  thus  reached. 
In  questioning  patients  to  ascertain  the  date  of  last  menstrua- 
tion, the  answer  elicited  will  usually  refer  to  the  date  of  the 
beginning  of  menstruation,  instead  of  the  end,  the  day  desired. 


LATERAL  SURFACE  OF  THE  PELVIS. 


CHAPTER    IX. 

NORMAL  LABOR;  THE  HEAD  PRESENTING. 

BY  labor  is  understood  that  process  of  contraction  of  the  uterus 
and  abdominal  muscles  which  results  in  the  extrusion  of  the  foetus. 
It  may  be  commonly  divided  into  three  stages ;  the  first,  the  stage 
extending  from  the  beginning  of  expulsive  uterine  contraction 
until  the  birth-canal  is  fully  dilated  ;  the  second,  the  interval  oc- 
cupied by  the  extrusion  of  the  foetus ;  the  third,  the  time  required 
for  the  delivery  of  the  membranes  and  placenta. 

The  characteristics  of  the  first  period  of  labor  vary  in  different 
individuals  in  first  and  subsequent  labors.  Intermittent  uterine 
contractions  occur  frequently  during  pregnancy,  and  have  much 
to  do  with  accommodating  the  foetus  to  the  birth-canal.  The 
beginning  of  a  first  labor  is  usually  characterized  by  an  intensifi- 
cation of  these  wave-like  uterine  contractions,  occupying  a  vary- 
ing number  of  hours.  Thus  a  patient  may  be  in  this  stage  of 
labor  for  one  or  two  days  before  active  pains  begin.  As  the 
name  indicates,  uterine  contractions  or  labor  pains  are  attended 
by  suffering.  Nerve  fibres  in  the  walls  of  the  uterus  are  com- 
pressed by  the  contractions  of  the  uterine  muscle,  and  nerve 
trunks  lying  along  the  brim  of  the  pelvis  are  also  subject  to  con- 
tusion. The  stage  of  intermittent  uterine  contraction  is  marked 
by  the  dilatation  of  the  os  uteri  and  the  gradual  obliteration  of 
the  cervix.  When  this  process  is  completed,  the  membranes 
commonly  rupture,  and  the  actual  expulsion  of  the  child  begins. 

The  diagnosis  of  labor  often  requires  perception  and  judgment 
on  the  part  of  the  physician.  He  will  frequently  be  called  to 
primagravidae  who  imagine  themselves  in  labor  because  abdomi- 
nal pain  is  experienced.  Acute  indigestion,  muscular  rheuma- 
tism of  the  walls  of  the  abdomen,  intercostal  neuralgia,  and  an  ex- 

61 


62  MANUAL   OF   PRACTICAL   OBSTETRICS. 

aggerated  nervous  condition  may  all  give  rise  to  the  sensation  of 
abdominal  pain.  The  practitioner  can  best  satisfy  himself  as  to 
the  presence  or  absence  of  genuine  labor  pains  by  placing  his 
patient  in  a  comfortable  position  upon  a  bed  or  couch,  and  hav- 
ing her  clothing  so  arranged  that  his  hand  can  rest  upon  the  ab- 
domen. He  will  then  appreciate  the  frequency  and  vigor  of 
uterine  contractions,  and  after  a  short  time  of  observation  can 
generally  determine  whether  labor  has  actually  commenced  or 
not. 

The  arrival  of  the  physician,  especially  if  he  be  a  stranger,  will 
not  infrequently  cause  the  pains  of  the  first  stages  of  labor  to 
cease  for  a  short  time.  Tact  should  be  used  in  approaching  a 
parturient  patient  for  the  first  time,  and  the  physician  will  do  well 
not  to  enter  her  room  until  his  coming  has  been  announced  and 
a  few  moments  have  elapsed.  During  the  second  stage  of  labor 
uterine  contraction  will  usually  go  on  without  interruption. 

As  labor  proceeds,  the  sensations  of  pain  which  at  first  are 
diffused  through  the  abdomen  will  commence  in  the  back,  exten- 
ding along  the  sides  of  the  abdomen  to  the  supra-pubic  region. 
Although  intermittent,  they  will  increase  in  frequency  and  sever- 
ity until,  the  membranes  having  ruptured,  they  become  later  in 
labor  almost  continuous.  Positive  information  regarding  the  ex- 
act stage  of  a  labor  can  be  obtained  by  internal  examination 
only.  In  multigravidae,  experience  enables  a  patient  to  estimate 
with  greater  accuracy  the  exact  stage  at  which  the  practitioner  is 
summoned.  A  vaginal  discharge  of  blood-stained  mucus  is  usu- 
ally a  symptom  of  the  dilatation  of  the  cervix,  and  the  beginning 
of  actual  labor. 

The  mechanism  of  labor  in  head-presentations  consists  of  the 
adaptation  of  the  head  to  the  brim  of  the  mother's  pelvis,  the  de- 
scent of  the  head  and  body  of  the  child  into  the  cavity  of  the 
pelvis,  the  rotation  of  the  child  as  a  whole  toward  the  anterior 
surface  of  the  mother's  body,  and,  finally,  its  expulsion.  During 
the  later  weeks  of  pregnancy,  the  intermittent  uterine  contractions 
to  which  reference  has  (Fig.  31)  been  made,  aided  by  the  elasticity 
of  tissues  previously  distended  will  generally  result  in  the  descent  of 


NORMAL  LABOR;  THE  HEAD  PRESENTING.  63 

the  presenting  part  into  the  cavity  of  the  pelvis  in  multigravidse. 
In  primagravidte,  however,  at  the  commencement  of  labor  the 
head  will  probably  be  found  at  the  brim  of  the  pelvis,  resting 

FIG.  31. 


THE  FCETUS  IN  A  PRIMAGRAVIDA. 


against  its  upper  edge  (Fig.  32).  The  movement  of  accommodation 
by  which  the  head  enters  the  pelvis  will  consist  in  adapting  the  di- 
ameters of  the  foetal  head  to  those  of  the  pelvis.  The  head  en- 


04  MANUAL   OF    PRACTICAL   OBSTETRICS. 

tering  obliquely  in  the  majority  of  cases,  the  vertex  being  at  the 
left  anterior  half  of  the  pelvis,  the  chin  and  face  of  the  child  will 
point  toward  the  right  posterior  portion.  It  will  be  remembered 


FIG.  32. 


THE  FCETUS  IN  A  MULTIGRAVIDA. 


that  the  oblique  diameters  of  the  pelvic  brim  in  the  living  patient 
measure  four  and  three-quarters  inches,  twelve  centimetres.  The 
occipito-frontal  diameter  of  the  head  measures  also  four  and  three- 


NORMAL  LABOR;  THE  HEAD  PRESENTING.  65 

quarters  inches,  or  twelve  centimetres.  By  relaxing  the  iliopsoas 
muscles  the  oblique  diameters  of  the  pelvis  are  capable  of  slight 
increase,  sufficient  to  enable  them  to  accommodate  the  occipito- 
frontal  diameter  of  the  head.  These  muscles  may  be  relaxed  by 
flexing  the  patient's  thighs  upon  the  abdomen,  and  this  simple 
manoeuvre  will  often  assist  in  the  descent  of  the  head  in  a  linger- 
ing labor. 

Should,  however,  the  head  be  large  for  the  pelvis,  it  may  become 
necessary  to  substitute  for  the  occipito-frontal  a  smaller  diameter. 
The  foetal  head  is  placed  upon  the  trunk,  like  a  lever  across  its 
fulcrum,  the  long  end  of  the  lever  being  the  distance  from  the 
chin  to  the  foramen  magnum.  The  tendency  shown  by  the 
human  head  to  drop  forward  upon  the  breast,  as  exemplified  in 
adults  as  well  as  in  infants,  illustrates  the  fact  that  the  preponder- 
ance of  weight  is  in  front  of  the  centre  of  gravity.  This  move- 
ment of  complete  flexion  substitutes  for  the  occipito-frontal 
diameter  the  sub-occipito-bregmatic,  which  averages  nine  and  five- 
tenths  centimetres,  or  three  and  three-fourths  inches.  In  the  oppo- 
site oblique  diameter,  the  left,  will  be  found  one  of  the  transverse 
diameters  of  the  foetal  head.  Thus,  when  the  occipito-frontal 
diameter  occupies  the  right  oblique  diameter  of  the  pelvic  brim, 
the  bi  parietal  will  be  in  the  left  oblique  diameter.  When  perfect 
flexion  has  occurred  with  some  descent,  the  bi-temporal  will  be 
found  in  the  left  oblique  diameter.  Both  of  the  transverse 
diameters  of  the  head  are  sufficiently  small  to  be  easily  accom- 
modated in  the  oblique  diameters  of  the  pelvic  brim.  The  head 
having  been  perfectly  flexed,  descends  gradually  through  the  pelvic 
brim  into  the  cavity  of  the  pelvis  (Fig.  33).  The  back  of  the  child 
remaining  directed  toward  the  left  side  of  the  mother,  the  trunk 
descends  as  the  head  precedes  it,  the  bis-acromial  diameter  of  the 
trunk,  which  measures  four  and  three-quarter  inches,  or  twelve 
centimetres  engaging  in  the  left  oblique  diameter  of  the  pelvic 
brim. 

When  the  foetus  has  descended  sufficiently  to  fairly  enter  the 
pelvic  cavity,  the  membranes  have  commonly  ruptured,  the 
amniotic  liquid  escapes,  and  the  exact  position  of  the  head  can 

3* 


66 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


readily  be  determined  upon  examination.  In  the  first  position, 
a  left  occipito-anterior,  the  sagittal  suture  will  be  found  occupy- 
ing the  right  oblique  FIG.  33. 
diameter  of  the  pelvis 
(Fig.  34)  Toward  the 
mother's  right  side,  and 
a  little  posterior  to  the 
centre  of  the  pelvic 
cavity,  can  be  felt  the 
anterior  fontanelle. 
This  landmark  is  not 
obliterated  by  the  pres- 
sure which  the  foetal 
head  undergoes,  and 
it  may  be  readily  dis- 
tinguished by  its  size, 
and  by  the  fact  that  out 
from  it  run  four  bony 
lines.  These  are  the 
sagittal,  the  fronto- 
parietal  of  each  side, 
and  the  suture  between  the  two  frontal  bones.  On  the  contrary, 
the  posterior  fontanelle  is  ordinarily  obliterated  by  the  pressure 
FlG  ...  exercised  by  the  walls  of  the  pelvis  upon 
the  foetal  head,  the  bones  sliding  under 
each  other  in  such  a  manner  as  to  fill 
up  the  interval  and  leave  simply  a  point 
of  convergence  of  three  sutures,  namely, 
the  sagittal  and  the  two  branches  of 
the  lambdoid.  In  head  presentations 
a  swelling  forms  on  that  portion  of  the 
head  which  is  not  pressed  upon  during 
labor.  It  results  from  infiltration  of 
the  scalp  with  bloody  serum.  In  ver- 
THE  HEAD  ENGAGING  IN  THE  tex  presentations  with  normal  rotation, 
PELVIC  BRIM.  it  is  found  on  the  upper  angle  of  the 


THE  DESCENT  OF  THE  FCETUS  IN  LEFT 
OCCIPITO-ANTERIOR  LABOR. 

x.  The  caput  succedaneum. 


NORMAL  LABOR;  THE  HEAD  PRESENTING. 


67 


FIG.  35. 


parietal  bone,  opposite  the  presenting  point ;  in  left  occipito-an- 
terior,  on  the  upper  angle  of  the  right  parietal  bone.  It  is  called 
the  caput  succedaneum. 

The  physician,  in  his  examination  at  this  stage  of  labor,  will 
find  this  point  of  convergence  (the  smaller,  posterior  fontanelle) 
upon  the  left  side  of  the  mother's  pelvis,  and  toward  its  anterior 

surface.  He  will  be  able 
to  distinguish  the  sagittal 
suture  extending  toward  the 
right  and  posteriorly,  and 
unless  the  tissues  are  firm 
and  resisting,  he  will  also 
be  able  to  find  the  anterior 
fontanelle. 

Labor  proceeding,  a  phe- 
nomenon of  rotation  occurs 
as  the  head  descends.  By 
rotation,  we  understand  the 
turning  of  the  head  upon 
the  pelvic  floor  so  that  its 
antero-posterior  diameter  is 
parallel  with  that  of  the  pel- 
vic outlet  (Fig.  35).  It  will 
be  remembered  that  the 
only  pelvic  diameter  at  the 
outlet  large  enough  to  per- 
mit the  expulsion  of  the 
head  is  the  antero-posterior, 
which  may  be  reinforced 
by  the  bending  backward 
of  the  coccyx  at  its  articulation  upon  the  sacrum.  Thus,  a  diam- 
eter of  from  twelve  to  fifteen  centimetres,  or  four  and  three-fourths 
to  over  five  inches  may  be  obtained.  The  anterior  turning  or 
rotation  of  the  head  brings  the  vertex  beneath  the  pubic  joint, 
the  occipito-frontal  diameter  resting  upon  the  antero-posterior 
diameter  of  the  pelvic  outlet.  The  vertex  being  forced  strongly 


DESCENT  AND  ROTATION. 


68 


MANUAL   OF   PRACTICAL   OBSTETRICS. 


FIG.  36. 


beneath  the  pubes,  the  neck  pivots  upon  the  sub-pubic  ligament 
(Figs.  36  and  37). 

Under  the  force  of  uterine  contractions  the  coccyx  is  bent  back- 
ward, and  the  forehead  and  face  of  the  child  are  forced  over  the 

pelvic  floor  and  peri- 
neum by  a  movement  of 
extension.  The  trunk 
meantime  follows  the 
head  with  a  correspond- 
ing rotation.  The  bis- 
acromial  diameter  hav- 
ing entered  the  pelvis  in 
the  left  oblique  diame- 
ter, the  trunk  descends, 
and  the  right  shoulder 
of  the  child  turning  to- 
ward the  pubic  joint  is 
first  forced  downward, 
emerging  beneath  the 


THE  HEAD  UPON  THE  PELVIC  FLOOR. 

joint  with  a  mechanism  similar 
to  that  which  the  occiput  has 
already  executed.  The  lower 
shoulder  is  then  extruded  by  a 
process  similar  to  the  extension 
of  the  face  and  chin,  and  the 
trunk  and  limbs  of  the  child 
follow.  The  fact  that  the  head 
rotates  and  emerges  before  the 
shoulders  causes  the  vertex  to 
turn  toward  the  left  thigh  of 
the  mother  as  soon  as  the  head 
is  born.  There  is  no  diameter 
of  the  trunk  of  the  foetal  body, 
except  the  bis-acromial,  suffi- 
ciently large  to  occasion  delay 
in  the  mechanism  of  labor, 


FIG.  37. 


BEGINNING  EXPULSION  OF  THE  HEAD. 


NORMAL  LABOR;  THE  HEAD  PRESENTING. 


69 


FIG.  38. 


and  the  head  and  shoulders  born,  only  a  mal-formation  in  mother 
or  child  will  occasion  delay  (Fig.  38). 

The  characteristics  of  the  second  or  expulsive  stage  of  labor  are 
stTong  contractions  of  the  uterus,  supplemented  by  those  of  the  ab- 
dominal muscles,  with  fixation  of  the  diaphragm  and  contraction 
of  such  of  the  muscles  of  the  trunk  as  are  necessary  for  this  phe- 
nomenon. At  the  moment  when  the  membranes  rupture,  there  oc- 
curs a  discharge  of  the  amniotic  liquid,  although  more  or  less  dis- 
charge of  blood-streaked  mu- 
cus has  been  going  on  during 
the  first  stage.  At  the  inter- 
vals  between  the  uterine 
contractions,  a  slight  pause 
occurs,  during  which  the 
patient,  if  fatigued,  often 
lapses  into  a  condition  of 
partial  stupor  or  sleep.  The 
surface  of  the  body  is  fre- 
quently covered  with  slight 
perspiration,  the  face  is 
flushed,  and  the  entire  or- 
ganism gives  evidence  of 
the  great  muscular  activity 
which  is  going  on.  The 
complaint  of  pain  increases 
as  contractions  become  more  violent,  until  the  pain  seems  unendur- 
able. Occasionally  a  condition  of  temporary  delirium  or  mania 
supervenes,  which  is  of  short  duration.  The  pulse  of  the  patient, 
although  quicker  than  usual,  is  firm  and  strong,  and  shares  in  the 
vigor  of  the  muscular  system. 

During  the  early  stages  of  labor  the  patient  will  naturally 
assume  such  a  posture  as  is  calculated  to  bring  the  head  well  into 
the  pelvis,  thus  facilitating  birth.  She  will  frequently  walk  about 
the  room,  assume  a  semi-recumbent  position,  and  often  kneel  at 
the  side  of  the  bed,  her  head  resting  upon  her  arms  which  are 
folded  on  the  body.  After  the  rupture  of  the  membranes  she 


RETROCESSION  OF  COCCYX. 

a,  b,  pubes.     c,  d,  curve  of  sacrum  and  coccyx  be 
fore  retrocession,     c,  tf  after  retrocession. 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


FIG.  39. 


instinctively  assumes  a  recumbent  position,  often  turning  from 

side  to  side  if  her  sufferings  be  severe. 

The  mechanism  of  labor  when  the  vertex  is  directed  toward 

the  right  side  of  the  mother's  pelvis  and  anteriorly,  corresponds 

to  that  already  described,  with  the 
simple  reversal  of  direction  in  rota- 
tion. Thus  the  head  and  trunk,  in 
the  first  instance  rotating  from  left 
to  right  toward  the  middle  line  of  the 
body,  in  the  second  instance,  turn 
from  right  to  left  toward  the  cen- 
tre. While  the  former  is  much  more 
frequent,  the  latter  is  not  to  be  con- 
sidered as  an  abnormal  labor.  Prac- 
tically, the  distinction  between  a  nor- 
mal and  an  abnormal  labor,  the 
head  presenting,  will  depend  upon 

two   factors:    presence  or  absence  of  flexion,  and  the  anterior 

or  posterior  rotation  of  the  occiput  (Fig.  39). 


HEAD  BORN  IN  RIGHT  OCCIP- 
ITO-ANTERIOR  LABOR. 


CHAPTER  X. 


ABNORMALITIES   OF   LABOR,    THE   HEAD    PRESENTING. 

A  NOT  infrequent  abnormality  of  labor,  the  head  presenting, 
is  the  failure  of  the  vertex  or  occiput  to  rotate  anteriorly  as  the 
head  descends.  Many  writers  describe  this  phenomenon  under 
the  head  of  occipito-posterior  positions,  but  the  simpler  and 
more  rational  explanation  is  to  view  them  as  cases  of  defective 
rotation,  and  not  as  separate  positions  and  mechanisms. 

The  physician  will   find  FIG.  40. 

early  in  labor  the  vertex 
presenting,  but  not  turned 
so  plainly  in  front  as  is 
usually  the  case.  The 
course  of  labor  is  more 
prolonged,  and  greater 
suffering  is  sometimes  ex- 
perienced. As  the  head 
descends,  the  vertex,  in- 
stead of  turning  to  the 
front,  remains  directed  pos- 
teriorly, and  finally  the 
head  reaches  the  pelvic 
floor  with  the  occiput  near 
one  or  other  of  the  sacro- 
iliac  joints.  If  the  expul- 
sive force  of  the  uterus  and 
the  abdominal  muscles  be 
normally  great,  and  the 
resistance  of  the  pelvic  floor  be  considerable,  the  head  being  flexed, 
the  occiput  will  turn,  in  nearly  nine-tenths  of  all  cases,  toward  the 
front,  and  the  expulsion  of  the  child  will  be  completed  as  usual. 
Should,  however,  the  resistance  of  the  pelvic  floor  be  deficient, 


THE  OCCIPUT  IN  THE  HOLLOW  OF  THE 

SACRUM. 


72  MANUAL   OF    PRACTICAL    OBSTETRICS. 

and  the  expulsive  forces  be  lacking,  flexion  being  incomplete, 
the  head  may  turn  into  the  hollow  of  the  sacrum  and  remain 
lodged  in  this  position.  The  conditions  necessary  for  anterior 
rotation  of  the  occiput  are,  sufficient  expulsive  force,  the  resist- 
ance of  the  pelvic  floor  and  the  maintenance  of  a  condition  of 
flexion  on  the  part  of  the  head.  When  any  of  these  factors  is 
deficient,  the  impaction  of  the  head  may  result  (Fig.  40). 

Another  abnormality  of  labor  in  head  presentations  occurs 
when,  from  any  cause,  the  antero-posterior  diameter  of  the  pelvic 
brim  is  so  much  lessened  as  to  encroach  upon  the  oblique  diame- 
ters, and  prevent  the  head  from  entering  in  one  of  them  as  is 
usual.  The  head,  in  attempting  to  enter,  will  then  turn  trans- 
versely to  the  entrance  of  the  pelvis,  the  occiput  upon  one  side, 
the  forehead  upon  the  other,  and  if  expulsive  efforts  continue,  the 
head  will  be  flexed  laterally  upon  the  spinal  column,  and  one  or 
other  of  the  parietal  bones  will  slip  downward  and  forward,  pre- 
senting at  the  entrance  to  the  pelvis.  This  is  known  as  a  Parie- 
tal-bone presentation. 

A  most  important  abnormality  in  head  presentations  is  that  by 
which  the  head  becomes  extended  instead  of  flexed.  Should 
partial  extension  occur,  what  is  known  as  a  Brow  presentation 
may  result,  the  lower  portion  of  the  forehead  and  the  superciliary 
ridges  becoming  the  presenting  part.  Should,  however,  com- 
plete extension  be  present,  a  Face  presentation  will  result. 

FACE  PRESENTATION. — This  abnormality  of  the  presentation 
of  the  head  is  definitely  named  in  accordance  with  the  portion 
of  the  head  which  is  considered  as  the  presenting  part.  Thus  the 
forehead  may  be  taken,  and  the  presentation  be  spoken  of  as  a 
Fronto  anterior  presentation.  Others  select  the  chin,  and  speak 
of  Mento- anterior  presentations. 

The  occurrence  of  either  will  be  best  understood  by  following 
a  case  of  Left  occipito  anterior,  or  first  occipital  presentation,  in 
which  the  head,  instead  of  becoming  flexed,  is  completely  exten- 
ded. As  the  occiput  rises  upon  the  left  side  of  the  mother's  pel- 
vis, the  forehead  descends,  and,  sweeping  through  an  arc  of  a 
circle  in  the  right  oblique  diameter  of  the  pelvis,  it  lodges  in  the 


ABNORMALITIES   OF   LABOR,    THE   HEAD    PRESENTING.  73 

left  anterior  compartment  of  the  pelvis,  formerly  occupied  by  the 
occiput.     The  chin  sinks  deeply  into  the  pelvis  pointing  toward 

FIG.  41. 


FACE  PRESENTATION  ;  LEFT-FRONTO-ANTERIOR. 

the  mother's  right  side  and  posteriorly,  the  back  of  the  child  re- 

4 


74 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


FlG.  42. 


maining  as  usual  toward  the  left  side  of  the  mother,  and  turned 
slightly  in  front  (Fig.  41). 

The  forehead  may  be  taken  as  the  presenting  part,  and  the 
presentation  and  position  will  then  be  called  Left-fronto-anterior. 
This  may  also  be  styled  the  first  position  in  a  Face  presentation. 
Should  a  similar  mechanism  be  executed  upon  the  right  side  of 
the  pelvis,  a  Face  presentation  in  the  second  position  would  re- 
sult. Others,  however,  prefer  to  take  the  chin  as  the  cardinal 
point  presenting  in  these  cases,  and  to  name  the  position,  Men- 
to-anterior  or  posterior.  Thus,  the  position  just  described  as 
Left-fronto-anterior  might  be  considered  a  Right-mento-posterior, 
and  similarly,  the  chin  may  occupy  any  one  of  the  four  compart- 
ments of  the  pelvis  (Fig.  42). 

The  mechanism  of  a  face  presentation  will  depend  upon  the 

degree  of  extension 
which  is  present.  In  a 
case  of  Left-fronto-an- 
terior, if  extension  be 
completed,  the  trachelo- 
bregmatic  diameter  of 
the  foetal  head  will  en- 
gage in  the  right  ob- 
lique of  the  pelvis.  In 
the  left  oblique  diame- 
ter will  be  found  the  bi- 
temporal  diameter  of  the 
head.  Each  of  these 
diameters  will  be  re- 
membered as  less  than 
four  inches,  or  ten  cen- 
timetres in  extent,  and 
hence,  is  not  sufficient- 
ly great  to  cause  delay 
in  rotation.  The  head 
descending  with  perfect 
extension,  the  chin  should  rotate  anteriorly,  and  engage  beneath 


RIGHT-FRONTO-ANTERIOR. 


ABNORMALITIES   OF   LABOR,    THE   HEAD    PRESENTING. 


75 


the  pubic  joint.  In  this  way,  first  the  thickness  of  the  head  from 
foramen  magnum  to  the  anterior  fontanelle,  and  then  the  thick- 
ness of  the  child's  trunk  above  the  shoulders  are  received  in 
the  antero-posterior  diameter  of  the  pelvic  brim,  the  chin  piv- 
oting beneath  the  pubes :  by  a  motion  of  flexion  the  occiput  is 
brought  down  over  the  concave  surface  of  the  sacrum,  the  coccyx 
and  the  distended  pelvic  floor,  finally  emerging  by  the  retroces- 
sion of  the  coccyx  at  the  sacro-coccygeal  joint.  If  perfect  exten- 
sion does  not  exist  as  the  head  descends,  its  maximum  diameter, 

FIG.  43. 


MECHANISM  OF  FACE  PRESENTATION. 

a.  Anus. 
f.  Fourchette. 
ur.  Urethra. 


B.  The  bladder. 

2  S.  Second  Sacral  Vertebra. 

R.  Rectum. 


or  the  occipito-mental,  will  be  brought  in  relation  with  the  di- 
ameters of  the  pelvic  brim,  and  impaction  will  result  and  labor 
cease  (Fig.  43). 

A  most  dangerous  complication  in  face  presentation  is  the  turn- 
ing of  the  chin  posteriorly  into  the  hollow  of  the  sacrum.  The 
antero-posterior  diameter  of  the  pelvis  must  then  receive  not  only 
the  thickness  of  the  head  from  the  occipital  region  to  the  anterior 


76 


MANUAL   OF    PRACTICAL   OBSTETRICS. 


fontanelle,  but  also  the  thickness  of  the  chest  of  the  child ;  the 
combined  mass  cannot  enter  the  pelvis,  and  hence  impaction  of 

FIG.  44. 


EXPULSION  OF  THE  HEAD  IN  FACE  PRESENTATION. 


FIG.  45. 


the  foetus  results.  The  factors  necessary  for  the  production  of  a 
normal .  mechanism  in  face  pre- 
sentations are  sufficient  expulsive 
force  in  the  uterus  and  muscles  of 
the  abdomen  ;  adequate  resistance 
of  the  pelvic  floor,  and  the  main- 
tenance of  extension.  A  position 
of  the  head  between  extension  and 
flexion  in  these  cases  must  result 
in  impaction  (Figs.  44  and  45). 

Cases  occur   not   infrequently 
in  which  the  head  is  born  last, 
but  this  will  be  considered  under      HEAD  BoRN  IN  FACE  PRESENTA. 
breech  presentation.  TION. 


Plate  II. 


Davis'  Obstetrics. 


CHAPTER  XI. 

THE    TREATMENT   OF   NORMAL   LABOR. 

THE  treatment  of  the  first  stage  of  labor  requires  the  exercise 
of  judgment  regarding  the  administration  of  drugs  which  might 
seem  naturally  indicated  in  this  condition.  When  the  physician 
finds  the  patient  actually  in  the  first  stage  of  labor,  if  she  be 
under  the  charge  of  a  competent  nurse,  he  will  do  well  to  disturb 
her  as  little  as  possible.  He  should  first  scrub  his  hands  tho- 
roughly with  soap  and  water ;  then  rinse  them ;  then  scrub 
them  in  bichloride  solution,  i  to  1000.  A  thorough  vagi- 
nal examination  will  then  assure  him  that  the  time  for  active  in- 
terference has  not  arrived.  There  are  no  active  means  by  which 
the  dilatation  of  the  birth-canal  can  be  hastened,  which  are  not 
fraught  with  danger,  and  which  should  not  be  reserved  for  urgent 
cases.  The  complaint  of  pain,  which  will  so  strongly  tempt  a 
physician  to  prescribe  narcotics,  is  the  most  distressing  feature  he 
has  to  encounter.  The  patient,  however,  should  be  diverted  as 
much  as  possible  from  a  consideration  of  her  sufferings,  while 
caution  should  be  exercised  that  her  strength  does  not  become 
exhausted.  She  should  be  encouraged  in  first  labors  to  remain 
up  and  about  as  long  as  possible,  assuming  any  position  most 
comfortable  to  herself.  The  nurse  should  see  to  it  that  the  bladder 
and  rectum  are  completely  empty,  and  if  any  suspicion  of  a  pre- 
vious inflammation  about  the  birth-canal  exists,  the  patient  should 
receive  a  vaginal  douche  of  bichloride  of  mercury,  one  to  five 
thousand.  Among  the  many  drugs  which  have  been  given  to 
mitigate  the  suffering  of  the  first  stage  of  labor,  chloral  and  anti- 
pyrine  are  most  deserving  of  confidence.  The  first  may  be  given 
in  doses  of  fifteen  grains,  repeated  hourly,  until  three  or  four 
doses  have  been  taken.  It  may  be  conveniently  administered  by 
rectal  injection,  as  the  stomach  of  the  patient  is  often  sensitive  at 

77 


78  MANUAL   OF   PRACTICAL   OBSTETRICS. 

this  time.  Antipyrine  may  be  given  in  doses  of  two  and  a  halt 
grains  each,  either  dissolved  in  water,  or  in  wafer  or  capsule.  The 
writer's  experience  has  shown  him  that  larger  doses  than  these 
of  antipyrine  result  in  delaying  labor,  while  small  doses  fre- 
quently give  the  patient  considerable  comfort.  The  drug  may 
be  repeated  three  or  four  times  at  intervals  of  one  or  two  hours. 

In  abnormal  cases  of  labor  where  it  is  feared  that  exhaustion 
may  result  from  delay  in  the  first  stage,  it  is  well  to  give  the 
patient  frequent  hot  douches.  These  should  be  rendered  anti- 
septic by  some  substance  which  does  not  destroy  the  natural 
smoothness  and  slipperiness  of  the  mucous  membrane.  A  one 
per  cent,  solution  of  creolin  will  be  found  best  adapted  for  this 
purpose.  Carbolic  acid,  one  per  cent.,  or  a  very  dilute  solution 
of  bichloride  of  mercury,  one  to  ten  thousand,  may  also  be 
employed. 

In  hospital  practice,  where  the  antecedents  of  patients  are  not 
known,  it  is  well  to  give  a  preliminary  douche  of  green  soap  and 
creolin,  sufficiently  strong  to  contain  two  per  cent,  of  the  anti- 
septic, before  labor.  The  writer's  experience  in  the  Philadelphia 
Hospital  has  convinced  him  of  the  decided  advantage  to  be 
gained  by  such  an  injection,  either  before  or  during  the  first  stage 
of  labor.  With  hospital  patients  a  full  bath,  either  in  a  tub,  or 
if  the  patient's  sufferings  will  not  permit,  by  a  sponge,  should  be 
invariably  given  ;  the  external  genital  organs  should  be  washed  in 
bichloride  solution,  one  to  two  thousand,  and  if  the  membranes 
have  ruptured,  an  antiseptic  napkin  should  be  worn  until  the 
physician's  arrival.  Should  this  stage  be  prolonged,  care  must 
be  taken  that  the  patient  receives  some  easily  digested  nourish- 
ment. Stimulants  should  be  avoided  unless  exhaustion  is  actually 
threatened. 

The  physician  should  discriminate  regarding  the  existence  of 
delay  in  the  first  stage  of  labor  from  the  inhibitory  action  of  the 
sensation  of  pain.  Thus,  labor  may  begin,  and  after  a  short  time 
the  pains  die  away,  the  patient  complaining  of  severe  suffering 
which  has  gone  to  the  point  of  nervous  exhaustion.  It  will  be 
well  then  to  give  the  patient  a  full  dose  of  some  anodyne,  putting 


THE   TREATMENT   OF   NORMAL   LABOR.  79 

her  perfectly  to  sleep  for  a  few  hours,  when  labor  may  go  on 
successfully.  An  injection  of  morphia,  one-eighth  of  a  grain, 
with  atropia  one  two-hundredth,  will  usually  be  found  best  for 
this  purpose. 

When,  however,  the  membranes  rupture  and  the  actual  expul- 
sion of  the  foetus  begins,  the  part  which  the  physician  is  to  play 
becomes  a  more  active  one.  The  patient  should  then  lie  upon 
her  left  side  upon  a  bed  suitably  prepared  by  the  nurse, 
a  pillow  or  blanket  roll  between  her  knees,  and  her  clothing 
should  be  so  arranged  that  it  may  readily  be  changed  after 
the  birth  of  the  child  without  great  disturbance  or  fatigue. 
The  physician  should  then  examine  the  patient  thoroughly  to  sat- 
isfy himself  of  the  position  and  presentation.  He  should  have 
at  hand  a  basin  containing  a  solution  of  bi-chloride  of  mercury 
one  to  two  thousand,  in  which  pieces  of  absorbent  cotton,  or  old 
linen,  are  immersed ;  he  needs  also  to  have  available,  Squibb's 
Fluid  Extract  of  Ergot,  brandy  or  whiskey,  a  hypodermic 
syringe  in  good  order,  tincture  of  strophanthus,  tincture  of  digi- 
talis, and  aromatic  spirits  of  ammonia. 

The  ligature  for  the  cord  should  have  been  previously  prepared 
from  silk  or  stout  thread  thoroughly  antisepticized.  The  physi- 
cian should  have  within  easy  reach  a  stethoscope,  a  pair  of  scis- 
sors suitable  for  cutting  the  cord,  a  small  blunt-pointed  bistoury, 
and  a  pair  of  haemostatic  forceps.  Beneath  the  edge  of  the  bed 
should  be  a  receptacle  into  which  soiled  pieces  of  cotton  or  linen 
may  be  thrown,  and  also  a  suitable  vessel  for  receiving  the  placenta. 

The  question  of  anaesthesia  during  normal  labor  is  one  admit- 
ting of  difference  of  opinion  and  discussion,  but  the  writer  is 
convinced  of  the  value  of  an  anaesthetic  given  to  a  mild  grade  of 
anaesthesia,  in  expediting  labor,  facilitating  delivery,  and  reduc- 
ing the  tendency  to  laceration  of  the  perineum.  It  is  his  custom 
to  use  chloroform,  and  a  mask  composed  of  canton  flannel 
stretched  upon  a  wire  frame.  This  flannel  may  be  readily  re- 
moved and  washed,  and  hence  cleanliness  in  this  respect  can  be 
easily  observed. 

As  labor  proceeds,  the  patient's  requests  for  relief  from  suffer- 


80  MANUAL   OF   PRACTICAL   OBSTETRICS. 

ing  may  be  met  by  allowing  a  few  drops  of  chloroform  to  fall 
upon  the  mask,  and  having  her  inhale  sufficient  to  appreciate  the 
odor  without  being  affected  by  it.  Should,  however,  it  become 
evident  that  the  patient's  pains  are  so  severe  as  to  threaten  exhaus- 
tion, it  will  be  well  to  encourage  her  to  inhale  sufficient  of  the 
anaesthetic  to  give  her  brief  periods  of  repose  between  the 
pains.  A  sleep  for  three  or  four  minutes  thus  obtained  will  often 
change  a  lingering  to  a  speedily  successful  labor,  and  prevent  the 
application  of  forceps. 

When  the  head  descends  upon  the  pelvic  floor,  the  physician 
must  choose  that  form  of  support  to  the  perineum  which,  in  his 
judgment,  best  reduces  the  risks  of  laceration.  The  writer  has 
no  hesitation  in  stating  his  belief  that  by  far  the  most  efficient 
method  of  delivery  is  that  taught  so  long  in  the  Vienna  Obstet- 
ric Clinics,  and  sometimes  denominated  "  The  Vienna  Meth- 
od." It  consists  in  placing  the  right  hand  broadly  extended 
upon  the  perineum,  the  curve  of  the  posterior  commissure  being 
received  in  the  space  between  the  thumb  and  index  finger ;  the 
left  hand  is  placed  between  the  patient's  thighs,  and  as  the  head 
emerges,  the  fingers  of  the  left  hand  in  a  semi-flexed  condition 
grasp  the  vertex,  holding  it  strongly  upward  beneath  the  pubic 
joint.  Should  the  patient  threaten  to  expel  the  child  suddenly, 
either  hand  may  be  placed  over  the  vulva,  the  other  pressing  upon 
it,  and  the  strength  of  both  arms  is  instantly  available  to  check 
the  too  rapid  progress  of  labor.  As  the  head  descends,  the  phy- 
sician cleanses  the  perineum  by  means  of  the  cotton  or  linen  im- 
mersed in  the  antiseptic  solution,  dropping  these  pieces  into  the 
waste  receptacle  beneath  the  edge  of  the  bed.  At  the  moment 
of  delivery,  he  requests  that  the  patient  inhale  the  anaesthetic 
deeply  to  complete  the  transient  anaesthesia.  Directing  or  main- 
taining the  flexion  of  the  head  by  the  left  hand,  with  the  right 
he  presses  the  head  backward  until  a  pain  has  ceased,  and  then  at 
a  favorable  opportunity,  having  tested  the  elasticity  of  the  peri- 
neum by  allowing  it  to  move  back  and  forth  under  the  right  hand 
as  the  head  descends,  he  slips  it  back  over  the  head,  allowing  the 
head  to  be  born  between  the  pains. 


THE    TREATMENT   OF    NORMAL   LABOR. 


8l 


FIG.  46. 


The  nurse  should  have  ready  a  solution  of  boracic  acid  and 
glycerine,  with  small  bits  of  old  linen,  and  as  soon  as  the  head  is 
born,  the  eyes  and  mouth  of  the  child  should  be  cleansed  with 
this  material.  During  the  brief  pause  which  occurs  between  the 
expulsion  of  the  head  and  the  shoulders,  the  patient  should  be 
allowed  to  rouse  partially  from  the  anaesthesia,  although  the  vigil- 
ance of  the  physician  should  be  in  no  way  relaxed.  His  left 
hand  should  grasp  the  neck  of  the  child,  bending  the  child's 
trunk  by  a  lateral  flexion  so  that  the  presenting  shoulder,  usually 

the  lower,  is  prevented  from 
ploughing  downward  into  the 
perineum.  The  right  hand  should 
still  support  the  pelvic  floor,  and 
thus  the  delivery  of  the  shoulders 
be  managed  upon  the  same  prin- 
ciples applied  to  the  birth  of  the 
head.  The  shoulders  born,  the 
anaesthetic  should  be  entirely  sus- 
pended, and  upon  the  expulsion 
of  the  child  the  nurse  or  physi- 
cian should  place  a  hand  upon 
the  fundus  of  the  uterus,  while 
the  child  is  allowed  to  lie  upon 
its  right  side  until  the  pulsation 
EPISIOTOMY.  of  the  cord  has  ceased.  A  tem- 

The  dotted  line  on  the  patient's  right  shows  ligature      may      then      be 

the  line  of  incision.   The  dark  oval  shows  f*"""*.J  t 

the  amount  of  dilatation  gained  by  thrown  about  the  COrd  three  fing- 

episiotomy  on  both  sides. 

ers"  breadth  from  the  umbilicus. 

If  the  child  is  asphyxiated,  and  haste  is  imperative,  the  cord  may 
be  clamped  by  the  haemostatic  forceps,  and  cut  without  ligation. 


The  child,  when 
separated  from  the 
mother,  is  wrapped 
by  the  nurse,  pre- 
ferably in  a  woolen 


FIG.  47. 


EPISIOTOMY  KNIFE  DEVISED  BY  THE  WRITER. 
blanket,  and  when  its  respiration  has  been  observed  to  be  normal, 


82  MANUAL   OF   PRACTICAL   OBSTETRICS. 

it  is  placed  aside  until  the  time  for  its  first  bath  (Figs.  46  and  47). 
In  cases  of  excessive  distention  of  the  perineum,  serious  rup- 
ture may  often  be  prevented  by  the  simple  procedure  of  episiot- 
omy.  This  is  effected  by  introducing  a  blunt-pointed  bistoury, 
or  a  blade  of  a  pair  of  blunt-pointed  scissors,  between  the  head 
and  the  edge  of  the  vulva  at  the  junction  of  the  upper  two-thirds 
with  the  lower  third.  The  extent  of  such  an  incision  will  de- 
pend upon  the  degree  of  distention;  but,  ordinarily  speaking, 
from  an  inch  to  an  inch  and  a  half  may  be  incised  without  dan- 
ger. The  blade  of  the  knife  should  be  turned  up  against  the 
edge  of  the  vulva  at  the  occurrence  of  a  pain,  when  the  tissues 
will  separate,  and  the  perineum  can  often  be  observed  to  retract 
to  a  remarkable  extent  over  the  presenting  part.  After  delivery, 
these  incisions  should  be  stitched  with  fine  catgut,  plentifully 
powdered  with  boracic  acid,  aristol  or  iodoform,  when,  as  a  rule, 
they  heal  promptly.  The  serre-fine  has  been  used  in  place  of  the 
suture  with  success. 


CHAPTER  XII. 


FIG.  48. 


THE   THIRD    STAGE   OF   LABOR. 

WITHOUT  narrating  the  many  theories  which  have  been  formed 
regarding  the  separation  and  expulsion  of  the  placenta,  it  seems 
in  the  present  state  of  our  knowledge  to  be  the  fact  that  the 
placenta  separates  from  the  wall  of  the  uterus  by  the  intervention 
of  a  clot  (Fig.  48).  It  is  expelled 
from  the  uterus  by  the  contractions 
of  that  organ,  and  especially  by  those 
of  the  abdominal  muscles.  The  time 
normally  occupied  for  the  accom- 
plishment of  this  is  sufficient,  first, 
to  allow  partial  separation  and  the 
formation  of  a  clot  to  occur ;  and, 
second,  to  give  the  patient  sufficient 
interval  in  which  to  recover  con- 
sciousness, if  she  has  been  anaesthet- 
ized, and  to  regain  control  of  the 
diaphragm  and  abdominal  muscles. 
When  labor  is  accomplished  with- 
out putting  the  patient  entirely  to 
sleep  at  the  moment  of  birth,  the 
placenta  may  follow  within  ten  or 
fifteen  minutes  after  the  expulsion 
of  the  child.  When,  however,  the  THE  PLACENTA  AND  MEMBRANES, 
patient  is  exhausted  or  has  been  After  the  expuUion  of  the  foetus, 
anaesthetized,  from  half  an  hour 

to  an  hour  may  elapse  before  uterine  contractions  bring  about  the 
expulsion  of  the  placenta  (Fig.  48). 

The  question  as  to  whether  active  interference  is  demanded 
must  be  determined  by  the  presence  or  absence  of  hemorrhage 

83 


84 


MANUAL   OF    PRACTICAL   OBSTETRICS. 


FIG.  49. 


and  the  consistence  of  the  uterus  as  felt  through  the  abdominal 
wall.  If  the  uterus  remains  moderately  firm,  and  there  be  no 
hemorrhage,  the  practitioner  should  wait,  if  the  labor  has  been 
normal,  until  the  patient  has  had  from  twenty  minutes  to  half  an 
hour's  rest,  and  is  able  to  make  voluntary  expulsive  efforts.  The 
left  hand  should  then  be  placed  upon  the  fundus  of  the  uterus, 
and  that  organ  roused  to  contract  by  gentle  friction  with  accom- 
panying pressure  in  the  axis  of  the  pelvis.  The  right  hand  of 
the  physician,  having  been  freshly  cleansed  and  antisepticized, 

should  examine  to  ascertain  the 
descent  of  the  placenta.  Usually 
a  few  vigorous  contractions  of 
the  uterus  and  abdominal  muscles 
will  bring  the  edge  of  the  pla- 
centa at  the  vulva  within  easy 
grasp  by  the  physician.  He 
should  then  fold  it  together  with 
the  thumb  and  fingers,  and  by  a 
gentle  rotary  motion  it  will  be 
felt  to  slip  easily  away,  the  mem- 
branes following  it  in  a  twisted 
cord.  The  nurse  should  hold  a 
suitable  receptacle  between  the 
patient's  thighs,  and  thus  the 
placenta  may  be  transferred  with- 
out exposure  and  with  but  little 
soiling  of  the  bed,  and  reserved 
THE  ABDOMEN  AFTER  THE  FCETUS  is  f  future  examination  (Figs.  50 
BORN. 


The  placenta  in  the  uterus. 


and  51). 

The  attention  of  the  physician 
should  next  be  directed  to  the  firmness  or  laxity  of  the  uterus. 
In  healthy,  young  primiparae,  the  mechanism  of  the  closure  of  the 
uterine  sinuses  is  amply  sufficient  to  guard  against  hemorrhage ; 
but  where  repeated  labors  have  weakened  the  uterus,  or  where  it 
has  been  relaxed  by  protracted  or  abnormal  labors,  it  is  the  part 
of  caution  to  administer  a  teaspoonful  of  the  Fluid  Extract  of  Er- 


THE   THIRD    STAGE   OF   LABOR.  85 

got.  In  some  cases  five  grains  of  quinine  will  act  more  efficiently 
than  ergot.  In  severe  cases  where  the  effect  of  the  drug  must  be 
obtained  at  once,  it  may  be  injected  into  the  walls  of  the  abdo- 
men in  doses  of  thirty  minims.  The  patient  should  now  be  left 
in  charge  of  the  nurse  to  be  properly  cleansed. 

FIG.  50.  FIG.  51. 


THE  EXPULSION  OF  THE  PLACENTA,         THE  PLACENTA  IN  THE  LOWER 
FCETAL  SURFACE  FIRST.  UTERINE  SEGMENT. 

The  physician  will  have  had  opportunities  during  the  progress 
of  labor  to  be  aware  of  the  presence  or  absence  of  lacerations  of 
the  pelvic  floor;  if  he  is  not  satisfied  as  to  their  existence  and 
their  extent,  he  will  do  well,  before  leaving  his  patient,  to  exam- 
ine thoroughly,  and  should  sufficient  laceration  be  found,  and 


86  MANUAL   OF   PRACTICAL   OBSTETRICS. 

the  condition  of  the  patient  permit,  it  should  be  closed  at  once. 
The  question  as  to  just  what  extent  of  median  laceration  of  the 
perineum  demands  suture  is  a  difficult  one  to  answer.  The  sani- 
tary regulations  of  some  of  the  countries  where  midwives  prac- 
tice extensively  under  license  require  them  to  summon  a  physi- 
cian to  close  a  laceration  of  more  than  one-half  or  three-fourths 
of  an  inch.  In  hospital  practice  it  is  safe  to  say  that  all  lacera- 
tions except  those  of  the  posterior  commissure  should  be  closed 
by  sutures.  Abrasions  of  the  mucous  membrane  or  stellate  tears 
in  the  mucous  membrane  of  the  vagina  should  be  heavily  pow- 
dered with  a  suitable  antiseptic  substance.  In  hospital  practice, 
iodoform  is  best;  in  private  practice  where  the  odor  of  iodoform 
is  so  objectionable,  powdered  boracic  acid  or  aristol  may  be 
employed  to  advantage.  It  will  not  infrequently  be  found  that 
instead  of  a  laceration  of  the  perineum,  the  mucous  membrane 
of  the  vagina  may  have  been  dissected  up  from  the  sub-mucous 
tissue  for  two  or  three  inches  at  one  side.  If  it  can  be  done 
without  too  much  suffering  and  inconvenience,  it  is  well  to  close 
such  a  laceration. 

The  immediate  closure  of  perineal  injuries  of  slight  extent  is  com- 
paratively a  simple  matter.  Curved  needles,  needle-holder  and  a 
pair  of  dissecting  forceps,  and  a  good  quality  of  antisepticized  silk 
will  usually  be  sufficient.  Silver  wire  is  preferred  by  some,  and 
the  over  and  over  stitch  with  catgut  by  others,  but,  as  a  rule,  the 
average  practitioner  will  do  better  with  silk  than  with  any  other 
material.  The  principle  of  closure  consists  in  simply  bringing 
together  lacerated  surfaces,  remembering  that  the  stitch  should 
go  sufficiently  deep  to  bring  the  wound  together  from  the  bottom. 
As  to  the  time  for  the  performance  of  this  slight  operation,  if  the 
patient  and  the  physician  be  exhausted,  if  the  light  be  poor,  and 
the  conditions  unfavorable  for  closing  a  lacerated  perineum, 
where  labor  has  occurred  during  the  night,  it  is  well  to  wait  four 
or  eight  or  even  twelve  hours  until  the  patient  has  become  some- 
what rested,  and  the  physician  can  perform  his  duty  under  favor- 
able circumstances.  A  great  advantage  in  immediate  closure  is 
found  in  the  fact  that  the  tissues  are  less  sensitive  to  pain  than 


THE  THIRD  STAGE  OF  LABOR.  87 

usual,  but  a  mild  degree  of  anaesthesia  will  relieve  the  patient  of 
suffering  if  the  operation  be  deferred. 

It  is  almost  needless  to  say  that  the  strictest  antiseptic  precau- 
tions should  be  observed  in  all  cases  of  labor.  After  a  normal 
labor  the  patient  should  be  given  one  vaginal  douche  of  bi-chloride 
of  mercury,  one  to  five  thousand.  Further  douches  are  superfluous 
and  often  injurious,  unless  complications  arise.  If,  however,  the 
patient  has  been  lacerated  and  stitches  have  been  inserted,  she 
should  have  two  and  possibly  three  vaginal  douches,  in  twenty-four 
hours,  of  bi-chloride  of  mercury  one  to  five  or  eight  thousand, 
creolin  one  per  cent.,  carbolic  acid  two  per  cent.,  thymol  one  to 
two  thousand,  or  a  saturated  solution  of  boracic  acid.  After  the 
douche,  the  parts  should  be  powdered  well  with  iodoform  or 
boracic  acid. 

After  attending  to  the  mother,  the  physician  should  examine 
the  placenta  and  the  membranes  to  assure  himself  that  no  part  of 
them  has  been  left  within  the  uterus.  He  may  also  note  any 
peculiarity  about  the  placenta  in  form,  size,  weight,  or  the  pres- 
ence or  absence  of  calcareous  or  fatty  degeneration  which  may 
be  present.  The  child  should  also  claim  his  attention,  and  he 
may,  at  his  leisure,  grasping  the  cord  at  the  umbilicus  with  the 
thumb  and  finger  of  the  right  hand  and  cutting  it  freshly  at  the 
ligature,  strip  or  squeeze  the  cord  from  the  umbilicus  outward.  A 
cord  which  is  not  rich  in  Wharton's  jelly  may  not  need  stripping, 
but  in  all  cases  where  the  cord  is  large  this  procedure  should  be 
attempted.  A  convenient  and  useful  method  of  dressing  the  cord 
is  to  powder  it  with  salicylic  acid  one  part,  and  starch  five.  It  is 
then  enveloped  in  absorbent  cotton  and  placed  upon  the  child's 
body,  pressing  gently  against  the  trunk  on  one  side  of  the  um- 
bilicus. A  knit  or  flannel  binder  is  then  applied  after  the  bath  of 
the  child,  and  the  cord  is  thus  protected  from  violence. 


CHAPTER    XIII. 

THE   TREATMENT   OF  ABNORMAL   LABORS,  THE   HEAD    PRESENTING. 

THE  treatment  of  abnormal  labors  in  head  presentations  must 
be  directed  to  secure  the  conditions  requisite  for  a  normal  mech- 
anism of  labor.  These  conditions  are  sufficient  expulsive  force 
on  the  side  of  the  mother,  the  resistance  of  the  pelvic  floor,  and 
the  flexed  position  of  the  head. 

As  regards  failure  of  the  mother's  expulsive  forces  the  most  com- 
mon example  is  lingering  labor  from  weak  pains.  Delay  from  this 
cause  is  most  often  seen  in  poorly  developed,  neurotic  primiparse, 
in  old  primiparae  where  the  birth  canal  is  not  easily  dilated,  and  in 
multipart  where  the  uterine  and  abdominal  muscles  have  been  so 
often  distended  that  they  have  lost  their  elasticity  and  contractile 
power.  The  cessation  of  expulsive  efforts,  before  the  membranes 
rupture,  is  attended  with  little  danger  to  the  mother  and  none  to 
the  child.  After  the  membranes  rupture,  both  are  in  danger  from 
protracted  labor.  The  complete  cessation  of  expulsive  efforts  after 
rupture  of  the  membranes  should  give  rise  to  the  suspicion  that 
the  foetus  and  the  birth  canal,  in  a  head  presentation,  are  dispro- 
portionate. It  cannot  be  too  strongly  urged  that  only  a  prelim- 
inary examination  by  pelvimetry,  palpation  and  auscultation  can 
enable  an  obstetrician  to  rationally  conduct  a  case  of  even  nor- 
mal labor.  When  by  such  examination  the  pelvis  has  been 
found  normal,  the  position  and  presentation  are  occipito-anterior, 
either  left  or  right,  and  the  head  has  engaged  favorably,  thus 
showing  a  normal  proportion  in  the  size  of  the  foetus  and  birth 
canal,  failure  of  the  expulsive  forces  before  the  membranes  rup- 
ture is  to  be  treated  by  anodynes  and  sedatives  to  secure  rest ;  by 
emptying  bladder  and  rectum;  by  small  quantities  of  easily  di- 
gested food,  and  by  allowing  the  patient  to  assume  such  postures 
as  conduce  most  to  her  comfort.  Occasionally  toughness  of  the 
88 


THE   TREATMENT   OF   ABNORMAL   LABORS.  89 

membranes  delays  labor,  when  the  obstetrician  must  rupture 
them ;  but  as  a  rule  the  membranes  should  be  left  to  rupture 
spontaneously. 

During  the  second  stage  of  labor  in  these  cases,  failure  of  ex- 
pulsive efforts  is  to  be  treated  first  by  posture  By  turning  the 
patient  on  that  side  to  which  the  presenting  part  is  pointing,  and 
flexing  her  thighs,  descent  and  rotation  will  be  facilitated.  In 
addition,  the  uterine  and  abdominal  muscles  may  be  stimulated 
by  friction.  This  is  best  done  by  commencing  to  rub  the  abdo- 
men and  gently  knead  the  uterus  when  a  pain  begins,  increasing 
the  rate  and  vigor  of  manipulation  as  the  pain  advances.  As  the 
pain  reaches  its  acme,  pressure  may  be  made  in  the  axis  of  the 
pelvis  and  continued  until  uterine  contraction  abates.  Drugs 
which  experience  has  shown  may  be  safely  employed  to  stimu- 
late expulsive  efforts  are  the  diffusible  stimulants,  as  alcohol,  tea 
and  coffee,  and  quinine.  The  last  is  advantageously  given  in 
capsules  containing  three  grains  of  quinine  and  one  or  two  grains 
of  scale  pepsin,  a  combination  which  does  not  usually  excite  the 
nausea  so  often  seen  at  this  time.  The  mother's  expulsive  efforts 
may  be  stimulated  and  encouraged  by  her  cooperation,  in  fixing  the 
diaphragm  and  bringing  the  necessary  expulsive  muscles  into  play, 
by  pulling  upon  a  sheet  tied  at  the  foot  of  the  bed,  or  grasping  the 
hand  of  an  attendant.  Whenever  the  sensation  of  pain  is  so  acute 
as  to  inhibit  expulsive  muscular  action,  an  anaesthetic  in  small 
doses  will  allow  the  reflex  mechanism  of  labor  to  proceed  success- 
fully. At  the  beginning  of  a  pain  the  patient  should  be  allowed 
to  smell  of  the  anaesthetic;  at  the  height  of  the  pain  she  may  ex- 
perience its  effects  sufficiently  to  enable  her  to  sleep  for  a  few 
minutes  when  the  pain  has  passed.  In  this  way  action  and  re- 
pose alternate,  and  progress  continues. 

An  abnormal  position  of  the  head  will  be  usually  discovered 
when  the  membranes  rupture,  as  the  obstetrician  should  then 
thoroughly  examine  the  patient.  It  can  best  be  remedied  by 
the  insertion  of  the  antisepticized  hand,  aided  by  the  administra- 
tion of  an  anaesthetic.  In  face  presentation  extension  is  to  be 
sought.  If  the  physician  detects,  early  in  labor,  that  the  occiput 

4* 


90  MANUAL   OF   PRACTICAL   OBSTETRICS. 

is  turned  posteriorly,  he  will  do  well,  before  the  membranes  rup- 
ture, to  place  the  patient  upon  the  side  toward  which  the  occiput 
is  pointing.  By  so  doing,  the  fundus  of  the  uterus  is  allowed  to 
incline  toward  that  side,  and  the  rotation  of  the  presenting  part 
is  favored  by  bringing  the  foetus  more  perfectly  into  the  axis  of 
the  birth-canal.  As  the  head  descends  the  hand  may  be  used  to 
push  up  the  forehead  and  favor  flexion.  The  expulsive  forces  of 
the  mother  should  be  conserved  by  the  administration  of  tonics 
or  stimulants,  and  should  these  forces  fail  the  forceps  is  indi- 
cated. It  must  be  remembered  that  labor,  when  the  head  turns 
posteriorly,  is  usually  longer  and  more  painful  than  normally, 
but  it  should  also  be  borne  in  mind  that  nearly  nine  tenths  of 
these  cases  terminate  spontaneously  with  an  anterior  rotation  of 
the  occiput. 

When  the  occiput  turns  into  the  hollow  of  the  sacrum,  great 
caution  is  needed  in  attempting  to  complete  delivery.  A  choice 
lies  between  the  forceps  and  craniotomy,  and  should  the  child 
have  perished,  the  latter,  in  skilful  hands,  is  the  better  of  the  two 
procedures.  The  method  of  applying  the  forceps  in  these  cases 
will  be  described  under  the  general  consideration  of  the  use  of 
this  instrument. 

The  treatment  of  brow  presentations  consists  in  the  endeavor 
with  the  antisepticized  hand  to  convert  a  brow  into  an  occipital 
presentation,  with  craniotomy  should  impaction  and  foetal  death 
occur.  Version  in  the  early  stages  of  labor,  when  dilatation  is 
complete,  is  also  indicated  in  brow  presentation,  when  the  pelvis 
is  normal  and  the  foetus  proportionate  in  size. 

Face  presentations  must  be  treated  by  securing  as  complete  ex- 
tension as  possible,  by  retaining  the  membranes  unruptured  to 
the  latest  moment,  and  occasionally,  by  the  use  of  the  forceps. 
When  the  head  is  turned  transversely  at  the  brim  of  the  pelvis, 
causing  the  presentation  of  a  parietal  bone,  the  case  demands 
most  cautious  treatment,  and  will  be  considered  under  the  head 
of  The  Treatment  of  Labor  in  Contracted  Pelves. 


CHAPTER  XIV. 

THE    FORCEPS. 

A  FREQUENT  complication  in  labor,  when  the  head  is  presenting, 
is  failure  of  the  mother's  expulsive  power,  necessitating  instru- 
mental delivery.  In  the  early  days  of  obstetric  science,  such 
cases  invariably  terminated  by  the  death  of  the  child,  and  its 
mutilation  and  extraction  by  sharp  hooks.  When,  however,  the 
idea  of  blunting  these  hooks  and  converting  them  into  a  harm- 
less tractor  arose,  the  forceps  was  invented. 

Its  model  was  doubtless  suggested  by  the  shape  of  the  hand 
about  to  grasp  a  round  object  like  the  head.  It  consists  of  two 
blades,  named  in  accordance  with  the  sides  of  the  pelvis  nearest 
which  they  lie,  the  left  and  the  right.  Each  blade  is  composed 
of  an  expanded  portion  for  grasping  the  head,  an  intermediate 
portion  bearing  some  device  for  fastening  the  two  blades  together, 
and  two  handles,  one  at  the  extremity  of  each  blade.  The  ex- 
panded portion  for  grasping  the  head  resembles  the  hand  ren- 
dered concave  by  flexion.  This  concavity  gives  to  this  portion 
of  the  forceps  blade  a  curve  called  the  Cephalic  Curve,  because  it 
is  intended  to  favor  the  approximation  of  the  instrument  to  the 
head.  From  the  tip  of  the  expanded  or  head  portion  of  the  for- 
ceps blade  to  the  handle  the  entire  blade  describes  a  curve  some- 
what resembling  the  axis  of  the  pelvis.  This  is  called  the  Pelvic 
Curve  of  the  forceps. 

In  the  centre  of  the  cephalic  portion  of  the  forceps  blade  is  an 
ovoid  aperture  called  the  Fenestra  of  the  blade.  The  device  for 
fastening  the  forceps  blades  together,  called  the  lock,  consists  in 
some  instruments  of  a  large  screw  with  thumb-piece  by  which  the 
upper  can  be  fastened  firmly  to  the  lower  blade  ;  in  others  of  a 
button-like  knob  placed  upon  the  lower  blade,  while  a  niche  in 
the  upper  blade  receives  the  stem  of  the  button  when  the  blades 


92  MANUAL    OF    PRACTICAL    OBSTETRICS. 

are  brought  together ;  the  lock  may  also  consist  of  a  loosely  fit- 
ting joint  formed  by  a  niche  in  the  lotver  blade  receiving  a  loose- 
ly fitting  ledge  upon  the  upper.  The  lock  most  frequently  in  use 
is  the  last,  which  is  exemplified  in  the  Simpson  forceps.  The 
material  of  which  the  forceps  is  made  is  tempered  steel,  plated 
with  nickle ;  the  handles  are  often  of  hard  rubber,  darkly  stained 
wood,  and,  occasionally,  of  metal  entirely,  the  purpose  of  the 
last  being  to  avoid  a  corrugation  which  in  wooden  handles  may 
give  lodgment  to  septic  material. 

Forceps  are  divided  commonly  into  long  and  short,  the  long 
being,  as  the  name  implies,  several  inches  greater  in  length  than 
the  short  forceps.  The  various  modifications  of  this  instrument 

FIG.  52. 


DAVIS  FORCEPS,  PERFORATED  FOR  Axis  TRACTION  TAPES. 

are  so  many  that  only  those  most  in  use  will  be  mentioned,  and 
especially  those  whose  merits  have  been  proven  by  personal  ex- 
perience. Forceps  may  be  divided  into  two  classes  as  construct- 
ed with  direct  reference  to  the  manner  of  application.  For  ex- 
ample, the  Simpson  forceps,  one  of  the  most  commonly  used,  is 
constructed  to  be  applied  to  the  sides  of  the  pelvis  without  re- 
gard to  the  rotated  or  unrotated  condition  of  the  head.  On  the 
other  hand,  the  Davis  forceps  was  shaped  to  be  applied  to  the 
sides  of  the  child's  head.  Various  other  instruments  are  inter- 
mediate in  construction,  but  each  is  made  with  some  reference  to 
this  manner  of  application  (Fig.  52). 

The  indications  for  the  use  of  the  forceps  are,  danger  to  the 
life  of  the  mother  or  child,  or  both,  arising  through  delay  in 
labor.  Occasionally,  in  precipitate  labor,  the  head  may  be  so 


THE   FORCEPS. 


93 


grasped  and  its  progress  controlled  by  the  forceps  as  to  render  the 
birth  a  normal  one  so  far  as  the  rate  at  which  the  child  is  ex- 
pelled is  concerned.  While  the  forceps  has  powers  as  a  lever, 
compressor  and  rotator,  yet  these  are  secondary  and  accidental, 
and  its  chief  and  important  function  is  that  of  a  tractor. 

The  conditions  under  which  the  forceps  may  be  safely  applied 
are  a  vertex  presentation,  very  rarely  a  presentation  of  the  breech 
or  face.  The  size  of  the  child  should  be  proportionate  to  that  of 
the  birth-canal  of  the  mother,  the  folly  of  attempting  to  drag  a  large 
head  through  a  small  pelvis  being  self-evident.  The  birth-canal 
must  be  dilated,  and  the  foetal  membranes  must  have  ruptured. 

The  dangers  attending  the  use  of  forceps  are  laceration  of  the 
maternal  tissues,  laceration  of  the  child's  scalp,  compression 
and  injury  of  the  child's  brain,  and  the  increased  risk  of  septic 
infection  accompanying  the  use  of  instruments.  Although  this 
instrument,  improperly  used,  is  one  of  the  most  dangerous  to 
mother  and  child,  yet  its  proper  employment,  under  antiseptic 
precautions,  does  not  increase  the  mortality  and  morbidity  of  labor 
beyond  a  very  slight  extent. 

The  first  and  simplest  complication  of  labor  for  which  the 
forceps  may  be  employed  occurs  when  the  vertex  presents  ;  rota- 
tion has  occurred ;  the  head  has  descended  to  the  pelvic  floor,  but 
the  mother's  expulsive  forces  failing,  the  life  of  the  child  is 
threatened  through  asphyxia,  and  the  mother's  tissues  are  in  danger 
through  pressure,  while  her  strength  is  well-nigh  exhausted.  The 
application  of  the  forceps  under  such  circumstances  is  known  as 
the  Low-application  or  Low-forceps-operation,  because  the  head 
is  resting  upon  the  pelvic  floor  when  the  instrument  is  applied. 
Danger  to  the  foetus  in  such  a  case  is  recognized  by  weakness  of 
the  foetal  heart,  with  rapid  beating,  and  sometimes  a  much  dimin- 
ished frequency  in  cardiac  action.  Danger  to  the  mother  in  such 
a  case  can  be  diagnosticated  by  her  exhausted  condition,  rise  in  her 
temperature,  rapidity  of  her  pulse-rate,  and  a  dry  and  swollen 
condition  of  the  birth-canal.  A  careful  physician,  however,  will 
not  wait  until  the  conditions  mentioned  are  present  in  the  birth- 
canal,  but  will  interfere  when  the  other  indications  exist. 


94  MANUAL   OF   PRACTICAL   OBSTETRICS. 

To  apply  the  forceps,  the  patient  is  placed  upon  her  back  across 
a  bed,  her  hips  brought  to  the  edge  of  the  bed,  and  her  feet  in 
chairs.  An  antiseptic  douche  should  be  given  before  the  appli- 
cation of  the  instrument,  and  the  physician  should  be  sure  that 
the  bladder  and  rectum  are  empty.  In  primiparae  an  anaesthetic 
should  always  be  administered ;  in  multiparae  it  is  sometimes 
possible  to  avoid  anaesthetizing  the  patient.  The  physician  should 
prepare  his  instrument  by  dipping  it  in  hot  water,  washing  it 
carefully  in  soap  and  hot  water,  rinsing  it  thoroughly ;  the  forceps 
should  then  be  placed  conveniently  in  a  pitcher  of  a  hot  anti- 
septic solution,  creolin  two  per  cent.,  carbolic  acid  two  and  a  half 
per  cent.,  being  convenient.  The  instrument  may  be  lubricated 
by  slightly  smearing  the  outer  surface  with  some  antiseptic  oint- 
ment, or  with  carbolized  oil.  The  physician  should  then  place 
himself  directly  opposite  his  patient,  so  that  he  can  appreciate 
any  deviation  from  the  central  line  of  her  body.  The  left  blade 
of  the  forceps,  or  lower  blade  is  to  be  inserted  first ;  the  hands 
having  been  thoroughly  cleansed  and  antisepticized,  the  fingers 
of  the  right  hand  should  be  introduced  into  the  vagina  between 
the  head  and  the  wall  of  the  birth  canal ;  grasping  the  left  blade 
of  the  instrument  at  its  centre  with  the  left  hand,  the  physician 
gently  inserts  the  left  blade  guided  by  the  fingers  of  the  right  hand. 
(Fig.  53).  To  facilitate  introduction,  the  left  blade  should  be  held 
with  its  handle  parallel  with  Poupart's  ligament  of  the  right  side ; 
the  thumb  of  the  right  hand  gently  pushes  against  the  posterior 
surface  of  the  cephalic  portion  of  the  blade,  the  instrument  gliding 
gently  between  the  head  and  the  fingers  of  the  right  hand  (Fig.  54). 
When  properly  applied,  the  forceps  blade  slips  in  almost  imper- 
ceptibly ;  the  handle  of  the  blade  will  tend  naturally  to  drop 
toward  the  floor,  and  should  be  held  by  an  assistant.  The  fingers 
of  the  left  hand  having  next  been  introduced  as  a  guard,  the 
right  blade  should  be  grasped  in  the  right  hand  of  the  physician, 
and  inserted  toward  the  right  side  of  the  mother's  pelvis.  If  it 
fits  easily  over  the  head,  an  effort  may  then  be  made  to  lock  the 
blades  by  allowing  the  right  or  upper  blade  to  fit  down  upon 
the  left,  and  the  parts  of  whatever  lock  may  be  present  to  adapt 


THE    FORCEPS. 


95 


FIG.  53. 


themselves  to  each  other.  If  the  forceps  will  not  lock  easily,  the 
blades  should  be  slightly  shifted  with  great  gentleness  until  they 
lock  easily. 

Locking  having  been  accomplished,  the  physician  may  then  by 
gentle  traction  try  to  move  the  head. 
A  very  moderate  force,  such  as  that 
exercised  by  the  fore- arms  of  the 
operator  only,  is  all  that  it  is  safe  to 
use.  Traction  should  imitate  so  far 
as  possible  uterine  contractions  and 
the  normal  expulsive  efforts  of  the 
mother.  If  the  mother  be  conscious, 
she  should  be  urged  to  "bear  down," 
and  traction  by  the  forceps  should 
be  simultaneous  with  her  effort.  If 
she  be  anaesthetized,  traction  may 
be  made  every  five  or  ten  minutes 
as  the  case  demands.  In  simple 
cases  such  as  that  under  consider- 
ation, the  force  should  be  directed 
first  slightly  downward,  then  di- 
rectly outward,  and  last,  upward. 
By  this  means  the  occiput  will  be 
brought  out  from  beneath  the  pubic 
joint ;  traction  directly  outward 
should  then  follow  until  the  head 
begins  to  distend  the  perineum. 
By  this  means  the  occiput  will 
have  emerged  from  beneath  the 
pubic  joint,  and  will  be  distend- 
ing the  vulva.  Traction  should 
then  be  almost  directly  upwards, 
w  hen  the  head  will  be  delivered  over  the  perineum. 

In  this  way  the  natural  mechanism  of  labor  is  imitated,  and 
laceration  of  the  perineum  through  downward  pressure  of  the  head 
may  often  be  prevented.  The  simple  procedure  of  Episiotomy, 


THE  LEFT  HAND  GRASPING  THE 
LEFT  FORCEPS  BLADE. 


96 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


to  which  reference  has  already  been  made,  is  especially  well 
adapted  to  such  cases.  After  the  delivery  of  the  head,  the 
shoulders  will  usually  follow  if  the  uterus  be  roused  to  con- 
traction by  friction.  After  delivery,  the  patient  should  receive  a 
thorough  douche  of  bi-chloride  of  mercury  one  to  five  thousand, 

FIG.  54. 


THE  INTRODUCTIOX  OF  THE  LEFT  BLADE  COMPLETED. 

and  any  slight  lacerations  should  be  thoroughly  dusted  with  an 
antiseptic  powder.  Although  lacerations  very  frequently  occur 
when  the  forceps  is  used,  yet  in  many  cases  a  laceration  is  pre- 
vented through  the  better  control  afforded  the  practitioner  by  his 
instrument  (Fig.  55). 


THE    FORCEPS. 


97 


In  other  countries,  the  patient  is  frequently  placed  upon  the  side 
during  forceps  delivery,  although  the  position  upon  the  back  is 
the  favorite  one  in  America.  The  low-forceps-operation,  or  use 
of  the  instrument  when  the  head  is  upon  the  pelvic  floor,  is  a 

FIG.  55. 


PROTECTION  OF  THE  PERINEUM  IN  FORCEPS  DELIVERY. 

Patient  upon  the  left  side. 

comparatively  simple  and  safe  procedure.     When,  however,  the 
head  has  not  rotated,  and  especially  if  the  head  be  situated  at  the 
brim  of  the  pelvis,  the  application  of  the  forceps  is  a  difficult  and 
dangerous  manipulation. 
5 


CHAPTER    XV. 

THE   APPLICATION    OF   THE  FORCEPS   AT  THE  BRIM   OF   THE  PELVIS  : 
AXIS  TRACTION. 

ANY  one  who  has  ever  introduced  the  instrument,  both  blades 
being  in  position  and  locked,  into  the  pelvis  of  a  skeleton  so  high 
that  he  could  grasp  a  head  situated  at  the  brim  of  the  pelvis, 
must  have  observed  that  when  traction  was  begun  with  the  forceps 
so  applied,  the  result  was  either  failure  to  cause  the  head  to 
descend,  or  its  extraction  with  great  difficulty.  If  the  cause  for 
such  difficulty  was  sought,  it  was  found  that  when  the  forceps  was 
turned  strongly  forward,  the  tips  of  the  cephalic  portions  of  the 
blades  impinged  against  the  walls  of  the  pelvis,  and  progress  be- 
came impossible.  In  a  living  patient,  the  lining  membrane  of 
the  birth-canal  would  have  been  badly  lacerated  by  such  an  effort. 
If,  however,  a  piece  of  tape  be  passed  through  the  fenestrae  of  the 
forceps,  and  when  introduced  to  the  brim  of  the  pelvis,  traction 
be  made  downward  and  backward  by  pulling  upon  the  tape,  this 
difficulty  is  avoided,  and  a  comparatively  easy  traction  will 
result.  Remembering  that  the  direction  of  the  axis  of  the  birth- 
canal  is  downward  and  backward  until  the  pelvic  floor  is  reached, 
when  it  is  deflected  upward  and  forward,  it  will  be  seen  that  trac- 
tion in  this  direction  may  be  appropriately  termed  axis  traction 
(Fig.  56). 

Any  forceps  fitted  with  a  device  for  performing  this  manoeuvre, 
namely,  pulling  downward  and  backward  when  the  forceps  is  ap- 
plied at  the  brim  of  the  pelvis,  is  an  axis-traction-forceps.  The 
more  elaborate  of  these  instruments  possess  metal  tractors  hinged 
upon  the  cephalic  portion  of  the  blade,  which  are  not  detachable. 
The  simpler  axis-traction-forceps  have  some  convenient  device 
for  the  accomplishment  of  this  purpose  by  which  traction  is  gen- 
98 


APPLICATION    OF   FORCEPS   AT    BRIM   OF    PELVIS. 


99 


erallymade  with  tape  or  bandage,  the  whole  being  easily  attached 
or  disconnected.  Of  the  first  class  are  the  elaborate  instruments 
of  Tarnier,  Simpson  and  Breus,  and  their  modifications.  The 
latter  form  of  instrument  is  well  represented  by  the  tape  attach- 
ment devised  for  the  forceps  by  Poullet,  which  may  be  applied 
to  any  ordinary  pair. 

If  we  consider  the  best  means  of  promoting  flexion  in  cases  in 
which  rotation  is  deficient,  we  shall  see  that  traction  in  the  axis 

FIG.  56. 


Axis  TRACTION. 


a.  b.    Traction  with  the  ordinary  forceps. 
c  d.     Traction  with  the  axis  traction  forceps. 

of  the  pelvis  is  among  the  most  valued  of  resources.  The  axis- 
traction-forceps  then  is  especially  valuable  in  this  complication, 
and  hence  it  is  that  posterior  rotations  of  the  occiput  and  defec- 
tive rotations  are  often  best  treated  by  axis-traction. 

An  equal  advantage  in  face  presentations  is  often  gained  by  the 
use  of  such  an  instrument  in  the  ability  to  secure  perfect  extension. 
Before  proceeding  to  consider  the  application  of  the  forceps  at 


100 


MANUAL   OF    PRACTICAL   OBSTETRICS. 


the  brim  of  the  pelvis,  we  may  be  allowed  to  repeat  that  the  case 
already  described  is  the  simplest  condition  calling  for  the  use  of 
this  instrument,  namely,  failure  in  expulsive  force,  the  occiput 
presenting  and  having  rotated  anteriorly,  the  head  resting  upon 
the  pelvic  floor,  the  child  being  proportionate  in  size  to  the  pel- 
vis; the  function  of  the  forceps  is  simply  to  imitate  the  mechan- 
ism of  the  last  portion  of  the  second  stage  of  labor.  The  dan- 
gers attending  its  use  in  such  a  case  are  undue  compression  of  the 
foetal  head  and  laceration  of  the  perineum  and  pelvic  floor. 

We  next  proceed  to  the  more  serious  conditions  requiring  the 
use  of  the  instrument,  namely,  the  expulsive  forces  of  the  mother 
failing  before  the  head  has  descended  to  the  pelvic  floor  while 

FIG.  57. 


LUSK'S  TARNIER'S  AXIS-TRACTION  FORCEPS. 


rotation  is  as  yet  incomplete,  and  in  cases  in  which,  often-times, 
the  child  is  not  proportionate  in  size  to  the  mother's  pelvis. 
The  use  of  forceps  in  face  presentation  and  when  the  child  pre- 
sents by  the  breech,  is  comparatively  rare. 

It  not  infrequently  happens  that  the  mother's  strength  becomes 
exhausted  when  the  head  has  engaged  at  the  brim  of  the  pelvis 
and  before  descent  and  rotation  have  occurred.  In  such  cases 
the  dangers  of  exhaustion  and  foetal  death  are  greater  than  in  the 
cases  just  described,  as  are  the  risks  of  injury  to  the  mother  by 
the  instrument  itself. 

The  two  classes  of  instruments  already  described  were  designed 


APPLICATION    OF    FORCEPS    AT    BRIM    OF    PELVIS. 


101 


with  a  special  reference  to  these  cases.  Thus  the  Tarnier  axis-trac- 
tion-forceps and  the  Simpson  long-axis-traction  forceps  represent 
two  theories  of  application  (Fig.  57).  In  the  first,  the  operator 
endeavors  to  apply  the  forceps  accurately  to  the  sides  of  the  head ; 
the  instrument  is  firmly  secured  in  its  grasp  of  the  foetal  head, 
traction  is  made  in  the  axis  of  the  pelvis,  and  the  instrument  and  the 
head  are  allowed  to  rotate  together  (Fig.  58).  In  the  use  of  the  sec- 
ond instrument  mentioned,  the  forceps  is  applied  to  the  sides  of  the 
pelvis  and  in  the  pelvic  axis,  grasping  the  head  as  it  conveniently 

FIG.  58. 


TARMER'S  LATEST  AXIS-TRACTION  FORCEPS. 


can.  Intermittent  traction  is  then  made  in  imitation  of  labor 
pains  and  between  the  tractions  the  blades  are  slightly  separated, 
and  the  head  is  allowed  to  rotate  by  degrees  until,  by  the  time 
the  pelvic  floor  is  reached,  it  has  fitted  itself  gradually  to  the  in- 
strument (Fig.  59). 

The  first  method  of  application  is  the  more  difficult ;  the  second 
is  comparatively  easy,  but  requires  discrimination  and  skill  in  fa- 
voring the  rotation  of  the  head.  We  have  employed  for  some 


102  MANUAL   OF   PRACTICAL   OBSTETRICS. 

time  in  axis  traction  the  ordinary  Simpson  forceps  to  which  we 
have  adapted  the  tape  attachment  of  Poullet.  A  brief  descrip- 
tion of  the  method  of  adapting  these  tapes  is  as  follows :  The 
blade  of  the  forceps  is  made  in  its  cephalic  extremity  a  little 
heavier  than  ordinary,  the  fenestra  of  the  blade  measures  four  and 
one-half  inches  in  length ;  two  and  one-half  inches  from  the  cephalic 
end  an  aperture  is  made  in  each  limb  of  the  blade  surrounding 
the  fenestra  one-quarter  of  an  inch  in  length,  one-eighth  of  an 
inch  in  width  ;  this  aperture  is  so  bevelled  as  to  present  no  sharp 
surface ;  through  it  is  passed  a  piece  of  strong  linen  tape  one-half 
inch  in  width,  inserted  from  within  outward  through  one  aper- 

FIG.  59. 


SIMPSON'S  AXIS-TRACTION  FORCEPS. 

ture,  and  then  from  without  inward  through  the  other ;  each 
piece  of  tape  is  one  yard  long,  or  eighteen  inches  after  it  has 
been  doubled  by  passing  through  the  forceps  blade ;  the  tapes 
are  received  in  a  traction  bar  consisting  of  a  straight  portion 
eight  inches  long  curving  downward  a  distance  of  four  inches,  and 
terminating  in  a  rotary  traction  handle ;  just  before  the  traction 
bar  curves  downward,  it  has  upon  the  upper  surface  a  cross  piece, 
two  and  one-quarter  inches  long,  which  has  at  each  end  an  aper- 


APPLICATION    OF    FORCEPS   AT   BRIM    OF   PELVIS.  103 

ture  for  making  fast  the  tapes  ;  the  end  of  the  traction  bar  which 
is  nearest  the  mother  has  a  rim  of  metal  through  which  the  tapes 
pass  to  be  tied  into  the  apertures ;  the  forceps  is  applied  to  the 
sides  of  the  pelvis  in  the  usual  manner,  the  tape  being  held  along 
the  blade  by  the  obstetrician  and  the  instrument  being  first  in- 
troduced on  the  left  side  of  the  mother  as  is  customary ;  care  is 
taken  that  the  tape  rests  between  the  forceps  blade  and  the  head 
of  the  child ;  the  tapes  are  then  passed  through  the  ring  of  the 
traction  bar,  passing  below  the  locked  forceps,  and  are  made  se- 
cure at  the  cross  piece ;  to  prevent  cutting  the  perineum  and  pos- 
terior wall  of  the  vagina,  Sim's  speculum  or  any  suitable  depres- 
sor or  guard  may  be  used. 

It  has  been  found  by  experience  that  a  special  screw  for  hold- 
ing the  forceps  firmly  locked  is  not  necessary;  extraction  is  made 
with  one  hand,  while  with  the  other  the  forceps  is  grasped  as 
usual  and  easily  held  and  applied  to  the  head  ;  the  pull  upon  the 
tapes  is  such  as  to  tend  to  keep  the  forceps  tightly  applied  to  the 
head  instead  of  drawing  the  blades  apart.  We  are  accustomed 
to  carry  the  tape  and  traction  bar  with  us,  using  the  forceps  with- 
out them  when  axis  traction  is  not  necessary.  The  fact  that  this 
attachment  can  be  fitted  to  any  forceps  with  which  the  practi- 
tioner is  familiar,  its  little  cost  compared  with  expensive  axis- 
traction  instruments,  the  ease  with  which  it  is  cleaned  and  car- 
ried in  the  regular  obstetric  bag,  have  made  the  instrument  a 
very  convenient  one  in  our  hands  (Fig.  60). 

The  high  forceps  operation,  or  the  application  of  the  instru- 
ment at  the  brim  of  the  pelvis,  is  admissible  only  when  the  child 
is  proportionate  in  size  to  the  birth-canal  of  the  mother ;  when 
the  head  has  at  least  partially  engaged  at  the  brim  of  the  pelvis ; 
when  there  exists  no  obstacle  to  delivery  in  the  centre  of  the 
bony  pelvis  and  at  the  pelvic  floor ;  when  the  membranes  have 
ruptured,  and,  as  is  the  rule  in  these  cases,  when  mother  or 
child,  or  both,  are  in  danger  from  delay. 

While  it  is  sometimes  possible  in  the  simple  or  low  forceps 
operation  to  perform  delivery  without  changing  materially  the 
patient's  position,  in  the  application  of  forceps  to  the  head  at 


104  MANUAL    OF   PRACTICAL   OBSTETRICS. 

the  brim  of  the  pelvis,  the  patient  must  be  brought  to  the  edge 
of  the  bed  or  table,  her  hips  projecting  over  the  edge  sufficiently 
far  t6  enable  traction  to  be  made  in  the  axis  of  the  pelvis.  An 
anaesthetic  is  nearly  always  indispensable.  As  in  all  obstetric 
operations,  the  bladder  and  rectum  should  be  thoroughly  emp- 
tied, and  means  should  be  at  hand  for  promptly  resuscitating  the 
child.  In  selecting  an  instrument,  the  average  practitioner  will 
do  better  with  one  to  which  he  is  accustomed  than  with  a  strange, 

FIG.  60. 


SIMPSON'S  FORCEPS, 

With  Poullet  Tape  Attachment  for  Axis-Traction. 

although  possibly  superior  instrument.  The  patient  being  anaes- 
thetized, a  thorough  examination  should  be  made  to  determine 
as  far  as  possible  the  exact  position  of  the  head.  If  the  operator 
purposes  to  apply  the  forceps  to  the  sides  of  the  pelvis,  the  blades 
may  then  be  introduced  as  usual  in  the  pelvic  axis,  and  passed  in 
sufficiently  far  to  grasp  the  head.  If  the  instrument  is  selected 
to  fit  upon  the  sides  of  the  head,  especial  care  should  be  taken 
to  apply  and  secure  it  in  the  proper  manner. 


APPLICATION    OF   FORCEPS   AT   BRIM   OF   PELVIS.  105 

With  the  former,  traction  should  be  made  downward  and 
backward  at  intervals  resembling  as  far  as  possible  the  contrac- 
tions of  the  uterus  during  labor.  Between  the  tractions  the  grasp 
of  the  forceps  should  be  slightly  relaxed  to  afford  the  head  an 
opportunity  to  rotate.  As  the  head  descends,  especial  care 
should  be  taken  when  the  pelvic  floor  is  reached  to  relax  the 
forceps  more  than  in  the  earlier  traction.  It  will  be  remem- 
bered that  it  is  not  until  the  pelvic  floor  is  reached  that  rotation 
occurs,,  and  hence  the  necessity  for  allowing  the  head  greater 
freedom  at  this  time.  If  the  Poullet  tapes  are  used,  they  can  be 
disconnected  from  the  traction  bar  after  the  pelvic  floor  is 
reached,  and  the  head  delivered  as  in  an  ordinary  application  at 
the  pelvic  floor.  If  the  axis-traction-forceps  with  non-detachable 
traction  bars  are  used,  these  bars  may  be  folded  up  upon  the 
shank  of  the  forceps  when  no  longer  in  use. 

In  applying  axis-traction  forceps  to  the  sides  of  the  head,  care 
should  be  taken  to  clamp  them  sufficiently  to  secure  a  firm  hold. 
Traction,  however,  should  be  made  as  in  the  former  case,  in  the 
axis  of  the  pelvis  toward  the  median  line.  The  use  of  the  for- 
ceps as  a  rotator  is  a  secondary,  and  not  a  primary  employment 
of  the  instrument.  The  forceps  and  head  must  rotate  together 
when  the  instrument  is  applied  to  the  sides  of  the  head ;  but  the 
rotation  must  be  effected  by  traction  in  the  axis  of  the  pelvis, 
and  not  by  forcible  rotary  movements.  Compression  and  lever- 
age are  also  secondary  functions  of  the  forceps ;  but  the  operator 
should  not  purposely  compress  the  head  to  any  great  extent,  nor 
pry  it  loose  from  an  impacted  position.  Only  such  compression 
and  leverage  as  are  incidental  to  the  securing  of  a  firm  grasp  and 
making  traction  in  the  axis  of  the  pelvis  are  admissible. 

Research  has  shown  that  the  diameters  of  the  fcetal  head  are 
lessened  in  some  directions,  and  enlarged  in  others,  by  pressure 
with  forceps.  If  the  forceps  is  so  applied  that  either  a  trans- 
verse or  antero-posterior  diameter  be  lessened,  the  vertical  diam- 
eter may  be  slightly  increased  without  serious  damage.  In  nor- 
mal labor  such  increase  takes  place  through  the  projecting  of  the 
parietal  bones  at  the  sagittal  suture,  and  this  may  be  imitated 


106  MANUAL    OF    PRACTICAL    OBSTETRICS. 

during  forceps  delivery.  A  physiological  pressure  upon  the  foetal 
head  may  be  said  to  be  such  as  would  force  cerebro-spinal  fluid 
from  the  ventricular  spaces  of  the  brain  into  those  of  the  cord, 
and  vice  versa,  thus  temporarily  lessening  the  volume  of  one 
portion  of  the  cerebro-spinal  nervous  axis  at  the  temporary  ex- 
pense of  the  other.  The  writer  has  observed,  after  several  cases 
of  forceps  delivery  where  the  death  of  the  child  resulted  within  a 
week  or  ten  days,  patches  of  cerebral  softening  not  resembling 
those  occasioned  by  embolism,  but  apparently  resulting  from 
pressure. 

When  the  head  does  not  engage  at  the  brim  of  the  pelvis,  as  a 
rule  the  forceps  should  not  be  applied.  Version,  or  some  other 
obstetric  operation,  is  then  indicated.  A  method  of  obtaining 
axis-traction,  sometimes  useful,  consists  in  passing  a  piece  of 
tape  through  the  fenestrae  of  the  blades  sufficiently  long  to  reach 
nearly  to  the  floor.  The  tapes  are  then  tied  together  while  the 
operator  makes  traction  by  the  handles;  the  loop  of  tape  is 
passed  about  his  feet,  and  downward  pressure  in  this  way  rein- 
forces the  usual  methods  of  traction. 

THE  USE  OF  THE  FORCEPS  IN  POSTERIOR  ROTATION  OF  THE 
OCCIPUT. — In  occipi to -posterior  positions,  it  will  be  remembered 
that,  as  a  rule,  rotation  occurs  when  the  head  reaches  the  pelvic 
floor.  To  secure  this  end,  however,  the  expulsive  forces  of  the 
mother  must  be  good,  and  the  resistance  of  the  pelvic  floor  be 
also  considerable.  Flexion  of  the  head  must  be  present  to  secure 
this  result.  The  use  of  the  forceps  in  these  cases  is  to  promote 
flexion,  and  aid  the  descent  of  the  head.  For  this  purpose,  axis- 
traction  is  desirable.  The  instrument  most  appropriate  is  that  of 
Simpson,  or  some  modification,  which  leaves  the  head  free  to  ro- 
tate as  labor  progresses. 

When,  however,  the  occiput  is  turned  directly  backward  into 
the  hollow  of  the  sacrum,  axis-traction  is  not  necessary,  and  de- 
livery can  usually  be  secured  by  applying  the  instrument  to  the 
sides  of  the  head,  and  making  traction  directly  outward  and 
slightly  downward  until  the  forehead  of  the  child  begins  to  ap- 
pear beneath  the  pubic  joint.  The  grasp  of  the  instrument  should 


APPLICATION   OF   FORCEPS   AT   BRIM   OF   PELVIS.  107 

then  be  relaxed,  the  handles  should  be  slightly  lowered,  and  a 
fresh  grasp  obtained.  A  movement  of  flexion  should  then  be 
performed  by  the  forceps,  the  handles  being  slowly  raised  to  allow 
the  occiput  to  pass  over  the  perineum.  In  such  cases,  laceration 
of  the  perineum  usually  occurs,  is  generally  considerable  in 
extent,  and  sometimes  complete. 

THE  FORCEPS  IN  FACE  PRESENTATIONS. — The  best  authorities 
agree  that  the  application  of  the  forceps  in  face  presentations  is 
not  to  be  commended.  It  is  true  that  a  narrow-bladed  straight 
instrument  has  been  employed  on  several  occasions  successfully, 
securing  perfect  extension,  and  favoring  the  rotation  of  the  chin 
anteriorly.  As  a  rule,  however,  the  use  of  the  instrument  results 
in  such  injury  to  the  child  and  the  mother  as  to  render  version  a 
far  more  desirable  expedient. 

THE  FORCEPS  APPLIED  TO  THE  BREECH. — In  cases  of  breech 
presentation  where  the  progress  of  labor  is  slow,  it  has  been 
found  possible  to  favor  descent  by  applying  the  forceps  in  such  a 
way  that  the  trochanter  of  each  side  should  fit  into  the  fenestra 
of  each  blade.  If  the  instrument  is  applied  in  any  other  man- 
ner, serious  injury  may  be  done  through  pressure  of  the  tips  of 
the  blades  upon  the  abdomen  of  the  child.  Traction  in  the  pel- 
vic axis  should  be  made. 

MORBIDITY  AND  MORTALITY  CAUSED  BY  THE  FORCEPS. — 
When  the  indications  for  the  use  of  the  forceps  are  intelli- 
gently comprehended,  and  the  instrument  is  rationally  employed 
with  strict  antiseptic  precautions,  its  use  does  not  increase  the 
maternal  morbidity  and  mortality  of  labor,  but  under  other  con- 
ditions a  very  considerable  increase  in  both  occurs.  The  injuries 
most  common  to  the  foetus  from  the  forceps  are  bruising  and 
laceration  of  the  scalp,  fractures  of  the  cranium  and  face,  and  in- 
juries to  the  brain  through  pressure.  It  occasionally  happens  that 
very  extensive  laceration  of  the  scalp  occurs,  followed  by  sloughing 
after  birth.  Fractures  of  the  cranium  and  bones  of  the  face  are 
rarely  fatal  of  themselves,  and  are  serious  in  proportion  as  they 
are  accompanied  by  injuries  to  the  brain  through  pressure.  Frac- 
ture of  the  jaw  rarely  occurs  and  will  often  recover  perfectly 


108  MANUAL   OF   PRACTICAL   OBSTETRICS. 

without  the  application  of  a  splint.  Paralysis  of  the  facial  nerve 
by  pressure  upon  the  trunk  soon  after  it  emerges  from  its  foramen 
is  not  uncommon,  but  is  usually  temporary  in  character.  Pres- 
sure upon  the  brain  may  produce  limited  areas  of  softening  as 
already  described,  and  even  death  from  extensive  injury  to  the 
vital  centres.  Although  it  has  been  believed  that  idiocy  is  often 
the  result  of  pressure  by  forceps,  yet  proof  of  this  is  wanting  in 
the  majority  of  cases,  while  a  causal  relation  between  forceps 
delivery  and  epilepsy  is  also  not  proven. 


Plate  III. 


Davis'  Obstetrics. 


Uterus  with  Twins  in  cranial  and   breech  presentation 
(two  ova).     (Smellie.) 


CHAPTER  XVI. 

LABOR  IN  BREECH  PRESENTATIONS. 

A  BREECH  presentation  may  be  diagnosticated  before  labor  by 
feeling  the  foetal  head  in  the  upper  portion  of  the  abdomen,  by 
hearing  the  foetal  heart  sounds  at  or  above  the  umbilicus,  by 
detecting  at  the  brim  of  the  pelvis  a  body  less  round  and  hard 
than  the  head,  and  by  mapping  out  the  foetal  limbs.  At  labor, 
such  a  presentation  will  be  suspected  when  the  head  cannot  be 
recognized  as  the  presenting  part  by  its  hardness  and  globular 
outline ;  a  diagnosis  can  be  made  with  certainty  when  the  thighs 
of  the  child  can  be  felt,  and  their  relative  position  to  the  trunk 
be  recognized. 

The  natural  course  of  labor  in  breech  presentation  is  more 
prolonged  than  when  the  head  presents,  because  the  breech  is 
inferior,  as  a  dilator  of  the  birth-canal,  to  the  head,  and  also 
because  delay  is  apt  to  occur  in  the  descent  and  delivery  of  the 
after-coming  head.  Nature  endeavors  in  these  cases  to  retain 
the  membranes  unbroken  as  long  as  possible,  thus  securing  thor- 
ough dilatation  (Fig.  61). 

The  positions  of  breech  presentation  are  designated  by  select- 
ing the  posterior  surface  of  the  sacrum  as  the  cardinal  point  upon 
the  foetus.  In  the  first  breech  presentation,  the  back  of  the 
.oetus  is  toward  the  left  side  of  the  mother,  the  posterior  surface 
of  the  sacrum  being  opposite  the  left  ilio-pectineal  eminence. 
The  diameter  of  the  foetal  body  principally  concerned  in  the 
mechanism  of  the  engagement  and  descent  of  the  breech  is  the 
bis-trochanteric,  extending  from  one  trochanter  to  the  other, 
measuring  three  and  three  quarter  inches,  or  nine  and  five-tenths 
centimetres.  When  labor  occurs  in  the  first  position,  this  bis- 
trochanteric  diameter  engages  in  the  right  oblique  of  the  pelvis. 

109 


I  10  MANUAL   OF   PRACTICAL   OBSTETRICS. 

The  body  of  the  child  descends  into  the  pelvic  cavity,  and  the 
anterior  hip,  in  this  case  the  left,  rotates  forward  under  the  pubes. 
If  the  child  be  small  and  the  birth-canal  capacious,  the  hips  may 
emerge  diagonally  across  the  outlet  of  the  pelvis.  The  body  is 
bent  slightly  upon  itself  by  lateral  flexion  as  it  emerges. 

In  normal  cases  the  arms  of  the  child  remain  folded  across  its 
breast.  The  left  shoulder  of  the  child  engages  first  under  the 
pubic  joint,  and  pivots  beneath  the  articulation  while  the  right 

FIG.  61. 


BREECH  PRESENTATION,  THE  LEGS  EXTENDED. 

First  Position. 

shoulder  sweeps  over  the  perineum.  The  back  of  the  child  then 
turning  anteriorly,  if  flexion  be  complete,  the  chin  emerges 
closely  approximated  to  the  breast,  and  the  occiput  pivots  be- 
neath the  pubic  joint.  Flexion  continuing,  the  head  passes  over 
the  perineum  from  the  chin  to  the  occiput  successively  by  a  mo- 
tion of  perfect  flexion.  When  the  back  of  the  child  rotates  pos- 
teriorly toward  the  back  of  the  mother,  the  chin  often  pivots 


LABOR   IN    BREECH    PRESENTATIONS.  Ill 

behind  the  pubic  joint,  and  delivery  may  take  place  by  expulsion 
with  strong  extension  (Figs.  62  and  63). 

When  the  back  of  the  child  is  toward  the  right  side  of  the 
mother  in  the  second  position  of  breech  presentation,  the  mech- 
anism is  the  same,  with  a  reversal  in  the  direction  of  the  rotation. 

The  treatment  of  breech  presentations  requires,  so  far  as 
possible,  very  early  recognition  of  the  presentation.  It  is  of  espe- 

FIG.  62. 


DESCENT  OF  THE  TRUNK,  BREECH  PRESENTATION. 

Second  Position. 

cial  importance  whenever  the  obstetrician  detects  an  abnormal 
presentation  that  the  membranes  be  not  ruptured  until  the  very 
last  moment.  One  of  the  dangers  to  which  the  child  is  exposed 
in  abnormal  presentations  arises  from  the  defective  dilatation  of 
the  os  and  cervix,  which  contract  about  the  head  and  neck  of  the 
foetus  at  the  moment  of  delivery,  often  causing  death  by  asphyxia. 
This  is  especially  true  in  labor  with  breech  presentations,  in  which 


MANUAL   OF   PRACTICAL   OBSTETRICS. 


the  head,  coming  last,  is  exposed  to  pressure  and  resistance  from 
an  imperfectly  dilated  birth-canal.     The  membranes,  then,  should 


FIG.  63. 


FIG.  64. 


THE  SHOULDERS  EMERGING,  BREECH 
PRESENTATION. 

Second  Position. 


EXPULSION  OF  THE  HEAD  IN 
BREECH  CASES. 

FIG.  65. 


be  retained  until  the  breech  has  de- 
scended, and  oftentimes  until  the 
membranes  begin  to  protrude  at  the 
vulva  (Figs.  64  and  65). 

In  a  simple  case  of  labor  with 
breech  presentation,  the  obstetrician 
should  avoid  hastening  the  descent 
of  the  trunk.  Traction  carelessly 
made  upon  the  hips  and  limbs  will 
often  cause  the  ascent  of  the  arms  to 
the  sides  of  the  head,  seriously  com-  HEAD  BORN  IN  BREECH  LABOR. 


LABOR    IN    BREECH    PRESENTATIONS.  113 

plicating  its  delivery.  As  the  breech  emerges,  the  wedge  formed  by 
the  breech  and  flexed  thighs  will  be  gradually  decomposed,  and  the 
limbs  will  become  gradually  extended.  It  occasionally  happens 
that  descent  of  the  limbs  is  present  from  the  beginning  of  labor, 
constituting  what  is  often  known  as  a  ''footling  case."  As  the 


FIG.  66. 


BRINGING  DOWN  THE  HIPS  IN  A  DELAYED  BREECH  LABOR. 

body  of  the  child  descends  the  physician  should  support  it  with 
his  hand,  or  with  a  warm  towel,  standing  ready  to  raise  the  body 
of  the  child  toward  the  mother's  abdomen  with  one  hand,  while 
making  prompt  and  energetic  pressure  over  the  uterus  behind  the 
pubic  joint  with  the  other,  at  the  moment  when  the  head  emerges. 

5* 


MANUAL   OF   PRACTICAL    OBSTETRICS. 


FIG.  67. 


These  two  simple  manoeuvres  will  result  in  the  prompt  expulsion 
of  the  head  in  uncomplicated  cases.     If  an  anaesthetic  has  been 

used,  itsadministration 
should  be  discontinued 
before  the  head  reaches 
the  pelvic  floor,  so  that 
the  mother's  conscious 
efforts  may  be  solicited 
at  the  critical  moment 
when  the  head  is  pass- 
ing (Figs.  66  and  67). 
It  is  well  in  all  breech 
cases  to  have  at  hand 
the  forceps  ready  for 
instant  use,  and  also 
appliances  for  resusci- 
tating an  asphyxiated 
child.  Of  the  latter, 
the  warm  bath  accom- 
panied by  a  fine  stream 
of  cold  water  directed 
upon  the  chest,  is  the 
best.  It  is  well  to  have 
a  small  English  cathe- 
ter which  may  be  in- 
troduced into  the  tra- 
chea, should  direct  in- 
flation of  the  lungs  be 
necessary.  In  the  ma- 
jority of  cases  an  as- 
phyxiated child  in 
whom  circulation  per- 
sists can  be  resuscitated 
by  placing  it  in  a  hot 
bath,  directing  a  fine 
BRINGING  DOWN  THE  TRUNK  IN  BREECH  CASES,  stream  of  cold  water 


LABOR  IN  BREECH  PRESENTATIONS.  115 

upon  its  chest  and  making  passive  respiratory  movements.  The 
application  of  cold  water  should  be  brief,  and  the  stream  should 
be  so  fine  as  to  resemble  a  jet  of  spray.  The  entrance  of  air  into 
the  foetal  chest  can  be  secured  by  Schultze's  method  of  inflation. 
The  foetus  is  grasped  by  both  hands,  the  palmar  surfaces  on  the 
scapulas,  the  thumbs  on  the  sternum,  the  head  between  the  hands. 
The  body  is  then  raised  until  the  legs  drop  over  the  physician's 
head;  it  is  swung  gently  outwards  and  forward,  in  the  arc  of  a 

FIG.  68. 


THE  ARMS  BESIDE  THE  HEAD. 

circle,  until  it  almost  touches  the  floor.  Expiration  occurs  during 
ascent;  inspiration  during  descent.  Should  the  heart's  action 
fail,  digitalis  or  strophanthus  given  by  hypodermic  injections,  and 
the  application  of  heat  are  often  useful.  The  precaution  should 
always  be  taken  to  remove  mucus  from  the  child's  mouth  and 
fauces  with  a  bit  of  soft,  old  linen  dipped  in  a  solution  of  boracic 
acid. 

When  the  arms  of  the  foetus  have  become  extended  beside  the 
head,  the  physician  must  liberate  them  and  bring  them  down. 
To  accomplish  this,  the  thighs  of  the  child  are  grasped,  we  will 


u6 


MANUAL   OF    PRACTICAL   OBSTETRICS. 


say,  by  the  left  hand ;  downward  traction  is  first  made  upon  the 
body,  and  then  the  trunk  is  bent  strongly  toward  the  mother's 
right  side  and  obliquely  upward  and  outward.  The  index  and 
middle  finger  of  the  right  hand  are  then  passed  over  the  child's 
right  scapula,  and  along  the  upper  surface  of  the  humerus,  until 
the  bend  of  the  elbow  is  reached.  The  foetal  arm  is  then  flexed  at 
the  elbow  and  carried  downward  and  across  the  child's  chest,  when 

FIG.  69. 


THE  ARMS  BESIDE  THE  HEAD. 

it  easily  drops  into  the  vagina.  Grasping  the  thighs  with  the  right 
hand,  the  body  is  then  carried  obliquely  upward  toward  the 
mother's  left  side,  and  the  left  arm  of  the  foetus  is  liberated  by 
the  left  hand  of  the  physician. 

The  arms  having  been  delivered,  an  effort  should  be  made  to 
deliver  the  head  by  the  simple  procedure  already  described. 
Should  flexion  not  be  well  marked,  the  head  may  delay  and  the 


LABOR    IN   BREECH    PRESENTATIONS. 


117 


life  of  the  child  be  lost  through  the  pressure  of  the  pelvic  floor 
upon  the  blood-vessels  and  nerves  of  the  foetal  neck.  It  is 
necessary  then  to  act  with  promptness.  The  physician  should 

FIG.  70. 


DELIVERING  THE  ARMS. 


stand  squarely  in  front  of  the  patient,  who  has  been  brought  to 
the  edge  of  the  bed  and  placed  across  it,  her  hips  projecting  over 
the  edge.  The  left  arm  should  be  uncovered  to  the  elbow,  thor- 
oughly cleansed,  and  should  be  turned  with  the  palmar  surface  of 


n8 


MANUAL   OF    PRACTICAL   OBSTETRICS. 


the  hand  upward.  The  body  of  the  foetus  should  then  be  placed 
astride  the  fore-arm  of  the  physician,  and  the  index  and  middle 
finger  of  the  left  hand  should  be  passed  upon  the  face  of  the 
child,  making  strong  pressure  upward  and  forward  upon  the  malar 
prominences.  Raising  the  body  of  the  child  upon  his  left  arm, 
the  physician  should  press  strongly  downward  with  his  right  hand 

FIG.  71. 


THE  DELIVERY  OF  THE  AFTER-COMING  HEAD. 

placed  behind  the  pubic  joint.  Should  he  not  succeed  in  promptly 
effecting  delivery,  he  may  place  the  middle  finger  of  the  left  hand 
in  the  child's  mouth,  the  index  and  other  fingers  resting  upon 
the  child's  shoulders.  He  may  thus  make  strong  flexion,  com- 


LABOR  IN  BREECH  PRESENTATIONS.  119 

bining  it  with  external  pressure,  and  urging  the  voluntary  efforts 
of  the  mother. 

If  great  resistance  is  to  be  overcome,  the  pressure  behind  the 
pubic  joint  may  be  made  by  an  assistant,  while  the  right  hand  of 
the  physician  is  placed  upon  the  child's  back,  the  fingers  of  the 
hand  grasping  the  shoulders  to  aid  in  traction.  When  the  back 
of  the  child  is  directed  posteriorly  toward  the  mother's  back,  the 
same  method  of  manual  extraction  is  indicated,  delivery  occurring 
with  the  occiput  behind ;  the  forceps  can  often  be  used  success- 
fully to  better  advantage  than  when  the  back  is  anterior  (Figs. 
68,  69,  70  and  71). 

The  morbidity  and  mortality  of  breech  presentations  is  not 
increased  especially  with  the  mother,  but  is  considerably  greater 
than  usual  with  the  child.  Asphyxia  and  exhaustion  through 
pressure  upon  the  after  coming  head,  the  inspiration  of  matter 
from  the  birth-canal,  and  injury  done  to  the  mouth  by  efforts  at 
delivery,  are  the  principal  dangers.  It  is  not  uncommon,  after 
the  delivery  of  the  child  in  breech  presentation,  to  have  the 
development  of  broncho-pneumonia  caused  by  inspiration.  The 
use  of  antiseptic  douches  during  the  early  stages  of  labor  dimin- 
ishes the  risk  of  such  pneumonia,  and  the  delivery  of  the  head 
without  the  introduction  of  the  finger  into  the  mouth  also  lessens 
risk.  The  causes  of  breech  presentation  are  sometimes  found  in 
a  relaxed  condition  of  the  uterus,  which  allows  the  foetus  to 
assume  various  positions  during  pregnancy.  In  twin  pregnancy, 
it  is  common  to  find  one  of  the  children  presenting  by  the 
breech.  Labor  is  longer  in  breech  than  in'head  presentations  as 
a  rule,  and  the  case  demands  patience  and  careful  attention. 


CHAPTER    XVII. 

LABOR   IN   TRANSVERSE   POSITIONS. 

IN  contracted  pelves  and  in  large  pelves  where  the  membranes 
rupture  suddenly  and  the  amniotic  liquid  escapes  rapidly,  the 
foetus  may  become  turned  transversely  across  the  birth-canal,  giv- 
ing rise  to  a  transverse  position.  The  part  which  usually  pre- 
sents in  these  positions  is  the  shoulder.  This  may  best  be  under- 
stood if  we  suppose  a  case  in  which,  during  the  latter  months  of 
pregnancy,  the  foetus  occupied  the  usual  position  in  the  uterus, 
that  is,  the  back  towards  the  mother's  left  side,  the  head  at  the 
brim  of  the  pelvis,  the  occiput  slightly  in  front.  If  now,  for  any 
reason,  as  contraction  at  the  brim  of  the  pelvis,  the  foetus  cannot 
descend  through  the  brim,  or  if,  by  the  sudden  rush  outward  of 
the  amniotic  liquid  the  foetus  be  suddenly  moved  downward,  it 
may  happen  that  the  head  will  delay  in  the  left  iliac  fossa,  the 
breech  will  be  near  the  right  iliac  fossa,  the  back  of  the  child  to- 
ward the  abdomen  of  the  mother,  the  feet  in  the  upper  portion 
of  the  right  side  of  the  mother,  while  opposite  the  left  ilio-pec- 
tineal  eminence  will  be  found  the  posterior  surface  of  the  right 
scapula.  As  a  rule,  should  labor  pains  continue,  the  right  arm 
of  the  foetus  will  descend  and  may  even  protrude. 

When  the  child  is  of  average  size,  its  descent  and  expulsion 
spontaneously  may  be  said  to  be  impossible.  It  is  true  that  a 
small  foetus  or  a  foetus  in  an  abnormally  large  pelvis  may  be  so 
folded  upon  itself  by  forcible  uterine  contractions  that  expulsion 
may  take  place.  This  occurrence,  however,  is  so  rare  that  the 
practitioner  should  never  count  upon  its  occurrence,  but  when 
the  transverse  position  is  detected  he  should  at  once  rectify  it  and 
terminate  the  labor  (Fig.  71). 

The  nomenclature  of  transverse  presentations  commonly  ac- 


LABOR    IN   TRANSVERSE   POSITIONS.  121 

cepted  designates  the  posterior  surface  of  the  scapula  as  the  car- 
dinal point  upon  the  foetus.  The  word  dorso  is  used  to  express 
the  fact  that  the  back  of  the  child  presents  in  these  cases.  The 
word  right  or  left  is  added  to  the  word  dorso  to  designate  the 
shoulder  which  is  presenting.  Thus  the  most  frequent  transverse 
position  is  that  in  which  the  right  shoulder  is  at  the  brim  of  the 
pelvis,  the  back  of  the  child  directed  in  front  as  has  been  already 
explained.  It  rarely  happens  that  the  back  of  the  child  is  turned 

posteriorly  (Fig.  72). 

FIG.  71. 


ATTEMPTED  SPONTANEOUS  EVOLUTION  IN  TRANSVERSE  POSITION. 

The  diagnosis  of  such  positions  and  presentations  may  be  made, 
first,  by  palpation,  and  then  by  internal  examination.  On  pal- 
pating the  abdomen,  the  head  can  usually  be  distinguished  upon 
one  side  above  the  brim  of  the  pelvis.  The  breech  can  generally 
be  recognized  upon  the  opposite  side,  and  if  the  transverse  posi- 
tion has  existed  for  some  time,  a  hand  and  arm  will  have  pro- 
lapsed, and  can  readily  be  found  upon  examination.  It  is  of 
practical  importance  to  recognize  promptly  which  shoulder  is 
presenting,  and  this  can  be  done  by  determining  which  hand  is 
prolapsed.  If  the  hand  and  fore-arm  of  the  foetus  is  turned  with 
6 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


the  radial  side  or  thumb  uppermost,  and   the  practitioner  grasps 
the  hand  as  if  to  shake  hands  with  it,  if  the  foetal  hand  fits  into 

his  right  hand,  palm 

FlG-  ?2-  to   palm,   the    foetal 

arm  is  the  right,  and 
the  right  shoulder  is 
presenting.  If,  how- 
ever, the  prolapsed 
hand  fits  the  left  hand 
of  the  practitioner,  it 
is  then  the  left  shoul- 
der which  is  present- 
ing (Fig.  73). 

A  further  diagnosis 

FIG.  73. 


RIGHT  DORSO-ANTERIOR. 

may  be  made  by 
reaching  the  axilla 
with  the  finger,  when 
the  ribs  of  the  child 
are  easily  distinguish- 
ed. Passing  the  finger 
over  the  shoulder, 
the  clavicle  and  the 
child's  neck  can 
sometimes  be  felt  ly- 
ing in  a  direction  op- 
posite to  that  in  which 
the  ribs  were  felt. 


RIGHT  DORSO-POSTERIOR. 


CHAPTER    XVIII. 

THE   TREATMENT   OF   TRANSVERSE   POSITIONS  ;    VERSION. 

IN  transverse  positions,  the  treatment  of  such  conditions  con- 
sists in  turning  the  child  about  so  that  its  long  axis  shall  co- 
incide with  the  axis  of  the  birth-canal.  This  may  be  accom- 

FIG.  74. 


COMBINED  VERSION  (First  Stage). 

plished,  first,  by  external  manipulation  only  ;  second,  by  external 
and  internal  manipulation  combined ;  and  third,  by  turning  the 
child  within  the  womb. 

To  accomplish  the  first  of  these  procedures,  the  membranes 
should  not  have  ruptured,  and  the  patient  should  not  be  in  active 
labor.  If  she  is  sensitive  and  the  abdominal  muscles  irritable, 

123 


124  MANUAL   OF   PRACTICAL   OBSTETRICS. 

she  may  be  partially  anaesthetized  with  ether  or  chloroform.  The 
practitioner  can  usually  outline  the  two  extremities  of  the  foetus, 
and  by  pressing  upward  upon  one  of  them  and  downward  upon 
the  other  by  a  series  of  gentle  sliding  movements,  either  the  head 
or  the  breech  can  usually  be  brought  to  the  brim  of  the  pelvis. 
This  procedure  is  known  as  "  External  Version." 

FIG.  75. 


COMBINED  VERSION  (Second  Stage). 

By  "Combined  Version,"  we  understand  a  method  by  which 
one  hand  of  the  physician  is  placed  upon  the  abdomen,  while  two 
fingers  of  the  other  inserted  within  the  vagina  and  cervix  endeavor 
to  lift  up  the  presenting  shoulder,  thus  dislodging  it  and  favoring 
the  turning.  The  external  hand,  by  pressing  upward  upon  the 
breech,  favors  the  descent  of  the  head.  This  method  is  often 
known  as  that  of  Braxton-Hicks.  It  is  appropriate  for  cases  in 
which  the  membranes  have  not  ruptured ;  when  the  os  and  cer- 
vix are  partly  dilated,  and  uterine  contractions  are  not  strong. 
To  perform  this  successfully,  anaesthesia  may  be,  but  often-times 
is  not,  required  (Figs.  74,  75  and  76). 

"  Internal  Version,"  or  turning  the  child  within  the  womb,  is 
the  procedure  necessary  in  cases  in  which  the  membranes  have 


THE   TREATMENT   OF   TRANSVERSE    POSITIONS;    VERSION.    125 

raptured,  or  are  ruptured  by  the  operator, 'and  in  which  there  is 
not  sufficient  time  to  perform  either  of  the  other  manipulations. 
Internal  Version  consists  in  introducing  a  hand  within  the  uterus, 
grasping  the  feet  of  the  child  and  bringing  them  down,  thus  con- 
verting a  transverse  into  a  breech  presentation.  Although  a  seri- 
ous procedure,  it  is  one  of  the  most  valuable  expedients  in  the 

FIG.  76. 


COMBINED  VERSION  (Third  Stage). 

obstetric  art,  and  when  skillfully  performed,  is  very  safe  for 
mother  and  child.  The  patient  should  always  be  anaesthetized 
and  placed  across  a  bed,  with  her  hips  projecting  over  the  edge. 
A  preliminary  antiseptic  douche  should  be  given,  and,  as  in  all 
obstetric  operations,  the  bladder  and  rectum  should  be  empty. 
Before  proceeding  to  turn,  the  operator  should  carefully  palpate 
the  abdomen  to  determine  the  presence  or  absence  of  excessive 


126 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


distension  of  the  lower  uterine  segment.  A  clear  diagnosis  of  the 
position  and  presentation  should  be  made,  and  from  such  diag- 
nosis the  situation  of  the  feet  of  the  foetus  can  be  readily  deter- 
mined. The  operator  will  then  select  for  introduction  the  hand 
which  will  pass  most  readily  to  grasp  the  feet  (Figs.  77  and  78). 

FIG.  77. 


INTERNAL  VERSION  (Grasping  the  Lower  Foot). 

Referring  to  our  original  example,  in  a  right-dorso  anterior  posi- 
tion and  presentation,  the  head  of  the  child  is  in  the  left  iliac-fossa 
of  the  mother,  the  feet  and  legs  of  the  foetus  lying  at  the  brim  of 
the  pelvis  and  posteriorly  upon  her  right  side.  As  the  obstetrician 
sits  before  her,  his  left  hand  can  be  introduced  most  readily  to  grasp 


THE   TREATMENT   OF  TRANSVERSE   POSITIONS;    VERSION.    127 

the  feet.  His  arm  should  be  uncovered  to  the  elbow,  rings  upon  the 
fingers  should  be  removed,  and  the  nails  cut  short  and  carefully 
cleaned.  The  hand  and  arm  should  then  be  thoroughly  antisepti- 
cized ;  the  back  of  the  hand  may  be  slightly  smeared  with  some 
antiseptic .  ointment.  To  introduce  the  hand,  the  patient  being 
anaesthetized,  the  thumb  and  little  finger  may  be  folded  toward 

FIG.  78. 


INTERNAL  VERSION  (Grasping  the  Upper  Foot). 


each  other,  thus  reducing  the  width  of  the  hand  very  considerably. 
The  hand  should  be  brought  in  such  relation  with  the  vulva  that 
its  greatest  diameter  of  width  will  be  parallel  to  the  greatest  di- 
ameter of  the  vulva.  The  right  hand  should  palpate  the  abdo- 
men externally,  endeavoring  to  push  up  the  foetal  head  while  the 


128 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


other  hand  brings  down  the  breech.     The  internal  hand — the 
left,  in  the  case  which  we  are   considering — should  be  gently 

FIG.  79. 


INTERNAL  VERSION  (Grasping  both  Feet). 

pushed  on  until  the  feet  of  the  foetus  can  be  grasped.  This  sim- 
ple manoeuvre  of  grasping  the  child's  feet  should  be  so  done 
that  the  finger  nails  of  the  operator  are  turned  away  from  the 


THE   TREATMENT   OF   TRANSVERSE    POSITIONS;    VERSION.    129 

uterine  wall  and  toward  the  centre  of  the  uterine  cavity.  To 
accomplish  this,  the  feet  should  be  seized  between  the  index  and 
middle  finger,  and  the  thumb  folded  over  upon  them  grasping 
them  firmly  in  the  palm  of  the  folded  hand,  as  shown  in  the  ac- 
companying illustration  (Fig.  79).  Traction  by  the  internal  hand 
should  be  slow,  gentle,  but  strong.  When  the  limbs  of  the  foetus 

FIG.  80. 


THE  NOOSE  m  VERSION. 

have  fully  descended,  the  external  hand  should  endeavor  to  push 
up  the  head,  thus  favoring  version. 

When  the  feet  have  been  brought  down,  if  haste  is  not  neces- 
sary, it  is  well  to  delay  the  extraction  of  the  child,  allowing  time 
for  the  mother's  uterine  contractions  to  expel  it.  If  there  be  a 
fear  lest  the  foetal  limbs  should  recede  within  the  uterus,  a  loop  of 
gauze  or  bandage  should  be  slipped  around  a  foot  or  hand.  When 
version  is  accomplished,  the  subsequent  course  of  the  labor  will 
be  simply  that  of  an  ordinary  breech  presentation  (Fig.  80). 


I30 


MANUAL   OF    PRACTICAL   OBSTETRICS. 


It  will  be  observed  that  version  by  external  manipulation  can 
be  performed  only  before  the  membranes  have  ruptured,  and  no 
considerable  degree  of  dilatation  of  the  os  and  cervix  exists. 

FIG.  81. 


THE  OBSTETRICIAN  ANESTHETIZING  THE  PATIENT  AND  PERFORMING 
VERSION  WITHOUT  ASSISTANCE. 

Version  by  combined  manipulation  requires  sufficient  dilatation  to 
permit  at  least  the  introduction  of  one  or  two  fingers.  The 
membranes  may  or  may  not  have  ruptured.  In  combined  version 
it  is  often  advantageous  to  introduce  the  four  fingers  through  the 


THE   TREATMENT   OF   TRANSVERSE   POSITIONS;    VERSION.     13! 

os,  thus  grasping  the  head  or  breech,  and  bringing  it  at  once  to 
the  desired  position.  To  perform  internal  version,  the  membranes 
must  have  ruptured,  or  must  be  ruptured,  and  dilatation  should 
be  at  least  almost  complete  Fig.  81). 

Version  is  further  divided  into  Cephalic  and  Podalic,  accord- 
ing as  the  head  is  brought  to  the  brim  of  the  pelvis,  or  the  feet 
are  brought  down,  as  in  internal  version.  Version  as  an  opera- 
tion will  be  further  considered  in  treating  of  labor  in  contracted 
pelves,  when  we  shall  find  that  in  transvere  presentations  in 
highly  contracted  pelves  it  may  be  necessary  to  lessen  the  size  of 
the  foetal  body  by  emptying  the  trunk  of  a  portion  of  its  con- 
tents or,  in  rare  cases,  by  cutting  through  or  dividing  the  trunk. 
So  far  as  nomenclature  of  these  presentations  goes,  we  have,  first, 
and  far  most  common,  right-dorso-anterior ;  second,  and  next  in 
frequency,  left-dorso-anterior,  the  dorso  posterior  positions  being 
rare. 


CHAPTER  XIX. 

LABOR  WHEN  THE  CHILD  AND  THE    BIRTH-CANAL    OF    THE    MOTHER 
ARE  DISPROPORTIONATE    IN    SIZE. 

A  CONSIDERABLE  number  of  cases  of  difficult  labor  arise  from 
the  fact  that  the  child  and  the  birth-canal  of  the  mother  are  not 
of  proportionate  size.  In  successive  pregnancies,  it  is  common 
to  find  a  slight  increase  in  the  size  of  children  born  after  the 
first.  Again,  conditions  affecting  the  mother's  nutrition  may 
also  influence  the  growth  and  size  of  her  child.  Thus,  children 
born  during  a  period  of  famine  are  naturally  smaller  than  chil- 
dren born  amid  plenty.  The  most  potent  influence  in  determin- 
ing the  size  and  type  of  the  foetus  is  found  in  the  size  and  type 
of  the  father.  For  example,  marriage  between  a  large  and  finely 
proportioned  man  and  a  small  and  ill-developed  woman  may 
result  in  children  larger  proportionately  and  better  developed 
than  the  mother,  although  rarely  attaining  the  stature  and  perfec- 
tion of  the  father's  form.  On  the  other  hand,  a  large  and  finely 
shaped  woman,  if  married  to  a  man  inferior  in  size  and  develop- 
ment to  herself,  may  give  birth  to  children  far  inferior  to  her  own 
excellences  of  form  and  feature.  The  influence  of  this  law  may 
be  illustrated  by  reference  to  an  actual  case :  an  ill-developed, 
badly-nourished  woman,  married  to  a  man  as  weak  and  poorly 
developed  as  she,  gave  birth  to  a  small,  ill-nourished  child  after 
a  short  and  easy  labor.  The  first  husband  dying,  the  mother 
married  a  large  and  well  developed  man,  and  became  the  second 
time  pregnant.  The  size  and  proportions  of  the  child  were  such 
that  labor  was  so  prolonged  and  difficult  that  the  Caesarean  Sec- 
tion was  seriously  contemplated  by  the  obstetrician  in  attend- 
ance. 

Cases  of  disproportion  between  the  size  of  the  foetus  and  the 
132 


LABOR   WHEN    DISPROPORTION    EXISTS. 


133 


birth  canal  may  be  conveniently  divided  into  those  in  which  the 
size  and  development  of  the  child  exceed  comparatively  those 
of  the  mother,  and,  second,  those  cases  in  which  the  birth-canal 
of  the  mother  is  contracted  either  by  a  deformity  in  the  bony 
pelvis,  or  by  a  foreign  growth,  or  previous  pathological  process  in 
the  mother's  soft  tissues.  In  cases  where  the  disparity  is  that  of 
size  and  development,  pelvic  measurements  will  reveal  the  fact 
that  the  pelvis  is  symmetrical  in  form,  although  often  below  the 
average  in  its  diameters.  Pelvimetry  then  gives  us  no  informa- 
tion regarding  the  amount  of  disproportion  in  the  size  of  the 
mother  and  child,  but  simply  indicates  that  the  mother  is  either 
of  average  size,  or  slightly  below.  There  is  no  practical  method 
available  for  measuring  the  child  in  the  uterus,  and  any  estimate 
as  to  the  relation  between  its  size  and  that  of  the  mother's  birth- 
canal  must  be  reached  by  some  method  of  practical  comparison. 

In  cases  in  which  the  head  is  presenting,  an  effort  should  be 
made  to  fit  the  head  into  the  bony  pelvis  as  a  head  is  fitted  into 
a  hat.  To  accomplish  this,  the  patient  should  lie  upon  her  back, 
the  thighs  flexed,  and  should  there  be  such  sensitiveness  or  irri- 
tability of  the  abdominal  muscles  as  to  cause  spasmodic  contrac- 
tion upon  pressure,  an  anaesthetic  should  be  administered.  The 
obstetrician  then  endeavors  to  press  the  head  of  the  child  gently 
into  the  pelvis  of  the  mother.  For  this  purpose,  a  hand  should 
be  placed  transversely  behind  the  pubes,  while  with  the  other,  an 
internal  examination  is  made,  and  the  descent  of  the  head  is 
appreciated.  If  an  assistant  is  available,  he  should  place  one 
hand  upon  the  fundus  of  the  uterus,  the  other  above  the  pubes, 
and  make  pressure  gently  as  already  described. 

By  engagement  is  understood  the  fitting  of  the  head  into  the 
brim  of  the  pelvis;  if  it  is  found  that  the  head  enters  the  pelvis, 
or  engages,  its  size  is  such  that  a  favorable  termination  of  labor 
may  be  expected  in  the  usual  way.  If,  however,  the  head  fails 
to  engage,  but  remains  above  the  entrance  to  the  pelvis,  some 
abnormality  exists  which  should  be  investigated. 

In  presentations  other  than  those  of  the  head,  we  have  no 
practical  method  of  estimating  the  relative  size  of  the  child  and 


134  MANUAL   OF    PRACTICAL    OBSTETRICS. 

the  birth-canal.  Thus,  if  the  breech  presents,  a  head  too  large 
to  pass  easily  through  the  pelvis  may  be  found  at  the  fundus  of 
the  uterus,  and  yet  no  accurate  idea  of  its  comparative  size  can 
be  obtained  by  palpation.  Excessive  distension  of  the  abdomen, 
the  complaint  of  the  mother  of  excessive  weight,  and  projection 
of  the  fundus  of  the  uterus  anteriorly,  may  point  to  the  presence 
of  one  very  large  child,  or  of  twins.  Auscultation  may  deter- 
mine that  but  one  foetal  heart  is  beating  in  the  uterus,  when  a 
rational  inference  would  be  that  one  child  of  excessive  size  was 
present. 

Practical  deductions  from  the  effort  to  estimate  the  propor- 
tionate size  of  mother  and  child  in  symmetrical  pelves  bear 
directly  upon  the  question  of  treatment.  If  the  head  can 
be  brought  to  engage  at  the  brim  of  the  pelvis,  and  if  the 
mother's  muscular  tissues,  both  of  the  uterus  and  of  the  abdomi- 
nal walls,  are  sufficiently  strong  and  firm  to  promise  good  expul- 
sive efforts,  the  case  should  be  left  to  proceed  spontaneously, 
with  the  expectation  that  the  patient  will  be  able  to  bring  the 
child  through  the  brim  of  the  pelvis  and  down  upon  the  pelvic 
floor,  where  its  delivery  can  usually  be  accomplished  by  the  use 
of  forceps,  if  necessary.  When,  however,  the  mother's  uterus 
and  abdominal  muscles  have  been  distended  by  previous  labors, 
and  their  efficiency  in  contracting  thus  lessened,  the  obstetrician 
will  not  expect  so  much  to  be  accomplished  in  delivery  by  the 
patient  herself.  When  dilatation  is  well  advanced,  he  must  be 
ready,  if  the  head  engages  but  slightly,  either  to  apply  the  for- 
ceps high  up  at  the  brim  of  the  pelvis,  or  to  perform  version. 
In  cases  where  the  head  is  so  large  that  it  will  not  enter  the  brim 
of  the  pelvis  at  all  under  pressure  from  above,  no  attempt  what- 
ever should  be  made  to  induce  it  to  enter  by  the  forceps;  but  a 
consultation  should  be  held  with  a  view  of  delivering  the  patient 
by  version,  craniotomy  or  a  Caesarean  section.  The  dangerous 
folly  of  attempting  to  drag  a  large  head  through  a  small  pelvis  is 
too  painfully  illustrated  by  actual  occurrence  in  practice  to  need 
further  demonstration. 


CHAPTER    XX. 

LABOR  COMPLICATED  BY  OBSTRUCTION  IN  THE  BIRTH-CANAL. 

LABOR  WHEN  THE  SOFT  PARTS  OF  THE  MOTHER  PRESENT  OB- 
STACLES TO  DELIVERY. — The  birth-canal  of  the  mother  may  be 
encroached  upon  by  lesions  of  the  soft  tissues.  The  most  fre- 
quent of  these  are  fibroid  tumors,  cancer,  ovarian  tumors  and 
contraction  from  stenosis  resulting  either  from  congenital  malform- 
ation or  from  the  presence  of  connective  tissue  produced  by  pre- 
vious inflammation  and  ulceration.  In  regard  to  the  presence  of 
fibroid  tumors  and  their  influence  upon  labor,  it  may  be  said 
that  labor  is  not  often  impossible  by  reason  of  this  complication. 
A  sub-peritoneal  fibroid  may  become  pedunculated  by  the  uter- 
ine contractions  at  labor,  and  such  tumors  are  sometimes  discov- 
ered after  the  patient's  recovery  when  previously  their  existence 
had  remained  unsuspected.  Such  a  tumor  may  be  demonstrated 
to  be  freely  movable  and  connected  with  the  uterus  by  a  pedicle. 
Interstitial  fibroids  may  delay  labor  by  their  presence  amid  the 
muscular  tissues  of  the  uterine  wall,  and  the  child  may  suffer  the 
effects  of  pressure  from  such  a  tumor  at  its  birth.  After  labor  an 
interstitial  fibroid  often  undergoes  partial  involution  with  the 
uterus.  Should  septic  infection  occur,  such  a  tumor  will  become 
gangrenous,  occasioning  a  serious  complication. 

Interstitial  fibroids  are  of  great  importance  in  cases  where 
Caesarean  section  is  performed.  When  the  incision  passes 
through  such  a  tumor,  it  will  not  subsequently  unite.  Necrosis 
of  the  fibroid  with  septic  absorption  has  been  the  result  in  cases 
of  Caesarean  section  where  these  growths  have  been  incised. 
This  furnishes  a  cogent  reason  for  performing  amputation  of  the 
uterus  in  such  a  case,  instead  of  the  usual  Caesarean  section. 
Submucous  fibroids  of  the  uterus  frequently  occasion  delay  in 

US 


136  MANUAL   OF   PRACTICAL   OBSTETRICS. 

labor,  but  rarely  preclude  the  possibility  of  its  termination. 
There  generally  occurs  a  movement  of  accommodation  on  the 
part  of  the  presenting  portion  of  the  foetus  and  the  tumor,  which 
results  in  slipping  the  tumor  upward  and  pressing  the  foetus 
downward,  so  that  birth  is  often  possible  where  at  first  the  out- 
look seemed  most  doubtful.  The  practitioner  will  do  well  not 
to  have  recourse  to  a  dangerous  obstetric  operation  upon  the 
mother  when  he  first  discovers  the  existence  of  such  a  tumor 
during  labor.  Should,  however,  the  fibroid  become  prolapsed, 
it  is  sometimes  possible  to  sever  its  pedicle  and  deliver  it  before 
the  birth  of  the  child.  Should  such  a  tumor  remain  after  the 
birth  of  the  child,  it  is  well,  if  possible,  to  remove  it.  Inversion 
of  the  uterus  has  sometimes  resulted  from  traction  made  by  the 
pedicle  of  a  submucous  fibroid  during  labor. 

In  cases  of  pregnancy  complicated  by  cancer  of  the  cervix, 
special  precaution  should  be  taken  to  keep  the  birth-canal,  so 
far  as  possible,  antisepticized.  Douches  of  creolin  or  carbolic 
acid  or  permanganate  of  potassium,  followed  by  the  free  use  of 
iodoform  in  combination  with  bismuth  or  boric  acid,  may  be 
employed  to  advantage  for  this  end.  If  the  cancer  be  discov- 
ered early  when  only  the  cervix  uteri  is  involved,  pregnancy  is 
no  contra-indication  to  the  immediate  removal  of  the  growth. 
When,  however,  the  cancer  has  penetrated  above  the  cervix,  the 
obstetrician  should  be  prepared  to  further  the  continuance  of  the 
pregnancy,  being  ready  to  remove  the  child  by  Caesarean  section 
when  viability  is  well  assured.  The  outlook  for  the  mother  after 
such  Csesarean  section  is  very  grave  from  the  danger  of  septic 
infection  in  the  uterine  incision  from  the  cancer.  By  the  free 
use  of  antiseptics  and  tamponing  the  vagina  with  iodoform 
gauze  during  the  operation,  it  is  possible  to  deliver  a  living  child 
without  materially  shortening  the  life  of  the  mother  or  increasing 
her  suffering.  When  the  cachexia  caused  by  cancer  is  borne  in 
mind,  it  will  be  seen  that  the  free  use  of  mercurial  douches  in 
these  cases  is  unadvisable  because  of  the  added  danger  of  mercu- 
rial intoxication.  It  is  quite  possible  for  labor  to  occur  in  a 
patient  having  cancer  of  the  cervix  and  for  the  labor  to  termi- 


LABOR   COMPLICATED   BY  OBSTRUCTION    IN    BIRTH-CANAL.     137 

nate  spontaneously.  If  dilatation  is  delayed  by  the  infiltration 
of  the  cervical  tissues  with  the  growth,  it  is  admissible  to  incise 
the  cervix  to  a  moderate  extent,  thus  facilitating  delivery.  By 
the  strictest  antiseptic  precautions  it  is  possible  in  these  cases  to 
preserve  the  life  of  the  child. 

Fibro-cystic  tumor  of  the  ovary  or  an  ovarian  cyst  may  com- 
plicate pregnancy  and  labor.  It  frequently  happens  that  the  pres- 
sure of  the  enlarged  uterus  upon  such  a  tumor  causes  necrosis  of 
its  tissues,  and  may  give  rise  to  septicaemia.  There  can  be  no 
question  of  the  duty  of  the  obstetrician  in  such  cases  to  at  once 
remove  the  tumor.  Pregnancy  will  generally  go  on  to  its  normal 
limit,  and  should  ovariotomy  be  necessary  at  the  beginning  of 
labor,  it  should  not  seriously  endanger  the  mother's  interests. 
Fibro-sarcomata  of  the  pelvic  tissues  form  a  most  serious  com- 
plication of  pregnancy  and  labor.  If  the  patient  is  seen  early 
in  labor,  amputation  of  the  uterus  is  indicated.  If  the  child  is 
dead,  however,  embryotomy  and  its  immediate  removal  are  the 
duty  of  the  obstetrician. 

In  cases  of  stenosis  of  the  birth-canal  arising  from  congenital 
malformation,  careful  examination  of  the  patient  should  be  made 
with  a  view  to  determine  the  possibility  of  incising  and  dilating. 
The  possibilities  of  nature  are  so  great  that  cases  seemingly  hope- 
less have  been  delivered  through  the  natural  channel.  This  is 
especially  true  in  cases  where  the  stenosis  is  the  result  of  congeni- 
tal malformation,  and  where  the  elasticity  of  the  tissues  has  not 
been  impaired  by  infiltration  with  pathological  products.  When 
it  is  decided,  however,  that  birth  cannot  proceed  normally,  the 
Caesarean  section  should  be  performed  so  soon  as  labor  pains 
begin.  It  should  be  remembered  that  the  obstetrician  is  not 
justified  in  amputating  the  uterus,  thus  destroying  a  patient's  power 
of  reproduction.  There  are  on  record  a  sufficient  number  of 
cases  of  repeated  Caesarean  operation  to  justify  simple  uterine 
incision  in  these  cases,  and  to  discourage  resort  to  amputation  of 
the  uterus.  In  cases  where  the  tissues  are  infiltrated  by  patho- 
logical products,  multiple  incisions  under  antiseptic  precautions 
have  sometimes  made  it  possible  to  deliver  a  viable  child  through 

6* 


138  MANUAL   OF    PRACTICAL   OBSTETRICS. 

the  natural  passage.  The  most  unfavorable  of  these  cases  are 
those  of  advanced  syphilis,  where  the  mother's  danger  of  septic 
infection  is  very  great.  Here  also  the  knowledge  that  the  foetus 
is  probably  infected,  should  lead  the  practitioner  to  regard  the 
interests  of  the  mother  more,  and  those  of  the  foetus  less,  in 
deciding  upon  his  treatment  of  the  case. 


CHAPTER    XXI. 

LABOR   IN    DEFORMED    PELVES. 

LABOR  IN  SYMMETRICALLY  LARGE  PELVES. — In  women  of  large 
stature,  and  often  without  apparent  cause  in  general  development, 
the  pelvis  is  found  symmetrical,  normally  shaped,  but  larger  than 
usually  the  case.  These  are  called  Symmetrically  Enlarged  (Justo- 
Major)  Pelves.  When  the  foetus  is  of  average  size,  labor  in  such 
pelves  is  rapid  and  easy.  Occasionally  the  child  turns  across  the 
pelvis,  or  the  cord  slips  down  and  prolapses,  when  version  is  re- 
quired. 

LABOR  IN  SYMMETRICALLY  SMALL  PELVES.— Such  pelves  are 
symmetrical,  normally  shaped,  but  below  the  average  in  dimen- 
sions. They  are  named  Symmetrically  Small  (Justo-Minor) 
Pelves.  Labor  and  its  treatment  in  these  pelves  have  been  con- 
sidered under  the  heading  "Labor,  when  the  Child  and  Birth- 
canal  of  the  Mother  are  Disproportionate  in  Size."  (Fig.  82). 

The  bony  tissues  of  the  mother's  birth-canal  may  be  deformed 
and  contracted  from  several  causes.  Rhachitis,  osteo-malacia, 
fractures  and  abnormalities  caused  by  abnormal  forces  acting  upon 
the  skeleton  during  the  period  of  development,  are  the  most  fre- 
quent causes  of  bony  deformities. 

It  will  be  interesting  to  note  some  of  the  factors  which  give 
to  the  pelvis  its  usual  contour  and  proportions.  The  most  ap- 
parent force  tending  to  push  the  sacrum  downward  and  forward 
is  the  weight  of  the  head  and  trunk  transmitted  through  the 
spinal  column.  Acting  at  nearly  right  angles  to  these  is  the 
force  exercised  in  walking  and  standing  by  pressure  by  the  heads 
of  the  femora  in  the  acetabular  cavities.  These  two  forces  are 
modified  by  the  elasticity  of  the  pelvic  bones,  and  by  the 
strength  of  the  ligaments  at  the  pubic  joint,  the  ischio-sacral 


140  MANUAL   OF   PRACTICAL   OBSTETRICS. 

and  coccygeal  ligaments,  and  by  the  inherent  tendency  through 
long  evolution  possessed  by  the  bony  tissues  of  the  female  organ- 
ism to  develop  after  its  type.  The  result  of  all  these  interacting 
forces  is  a  pelvis  of  average  proportions  (Figs.  83  and  84).  When, 
however,  any  one  of  these  factors  in  development  is  deficient,  there 
results  a  lack  of  symmetry  or  deformity  in  the  pelvis.  The  most 
simple  of  these  conditions  is  contraction  in  the  antero-posterior  di- 

FIG.  82. 


SYMMETRICALLY  SMALL  (JUSTO-MINOR)  PELVIS. 

ameter  only,  giving  rise  to  the  simple,  flat  pelvis.  This  occurs  in 
women  who  have  been  prevented  by  any  reason  from  exercising  the 
lower  limbs  during  childhood,  as  in  cases  of  infantile  paralysis, 
where  the  lower  extremities  have  been  partially  or  wholly  paralyzed, 
and  life  is  still  persistent.  Such  children  remain  principally  in  the 
sitting  posture,  thus  transmitting  weight  downward  upon  the 


LABOR    IN    DEFORMED    PELVES. 


141 


sacrum,  while  the  counteracting  forces  of  pressure  by  the  femora 
are  lacking.  In  many  cases,  no  cause  whatever  can  be  ascertained 
for  the  occurrence  of  this  deformity.  There  is  usually  no  sign  of 


FIG.  83. 


FIG.  84. 


THE  POSTURE  AND  ABDOMINAL  PROTRUSION 

IN  A  WELL-FORMED  PREGNANT 

WOMAN. 


POSTERIOR  SURFACE  OF  A 

\\  KLL-FORMED  FEMALE 

BODY. 


its  presence  in  the  stature  or  development  of  the  patient,  and 
hence  the  great  liability  of  the  obstetrician  to  overlook  such  a 


142 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


FIG.  85. 


deformity  unless  it  is  his  custom  to  universally  measure  th6  pelvis 
of  his  patient.  When  labor  occurs  in  a  simple,  flat  pelvis,  the 
head  will  naturally  turn  in  such  a  position  as  to  bring  one  of  its 
lesser  diameters  in  relation  with  the  smallest  diameter  of  the  pelvis. 
This  results  in  a  transverse  position  of  the  head  at  the  brim,  the 
bi-temporal  or  bi-parietal  diameter  being  brought  in  relation  with 
the  antero-posterior  diameter  of  the  pelvic  brim  (Fig.  85).  If  the 
contraction  be  not  excessive,  and  the 
patient's  expulsive  forces  be  good,  the 
head  will  descend  transversely  through 
the  brim  of  the  pelvis.  The  centre  of 
the  pelvic  cavity  and  the  pelvic  floor 
being  reached,  there  will  be  found  no 
obstacle  to  rotation,  and  labor  may  pro- 
ceed normally.  When,  however,  the 
narrowing  at  the  brim  of  the  pelvis  is 
considerable,  the  head  will  not  descend, 
but  will  remain  transversely  at  the  brim. 
The  pressure  of  the  uterus  continuing, 
one  of  the  parietal  bones  will  gradually 
descend  lower  than  the  other,  and  thus 
what  is  known  as  a  parietal  presentation 
will  result. 

So  far  as  the  question  of  detection  is 

concerned  in  such  pelves,  a  diagnosis  will  be  readily  made  by  any 
one  who  practices  pelvimetry  as  a  rule.  The  narrowing  of  the 
antero-posterior  diameter,  while  the  other  diameters  of  the  pelvis 
remain  unaltered,  renders  the  diagnosis  comparatively  simple.  If 
the  obstetrician  has  the  patient  under  his  charge  during  the  second 
half  of  her  pregnancy,  he  may  select  a  favorable  opportunity  for 
the  induction  of  labor.  It  has  been  found  that  the  greatest  trans- 
verse diameter  of  the  foetal  head  increases  most  from  the  thirtieth 
to  the  thirty-sixth  week.  Accordingly,  when  the  antero-posterior 
diameter  measures  eight  centimetres,  or  three  and  one-eighth 
inches  and  over,  we  may  delay  until  the  thirty-fifth  week  for  the 
induction  of  labor.  When  it  measures  seven  and  a  half  to  eight 


HEAD  ENTERING  A  FLAT 
PELVIS. 


Plate  IV. 


Davis'  Obstetrics. 


3 

CD 
0. 


?  I 


f 


LABOR    IN    DEFORMED    PELVES.  143 

centimetres,  or  two  and  nine-tenths  to  three  and  one-eighth 
inches,  the  thirty-first  to  the  thirty-fourth  week  may  be  chosen, 
and  when  this  diameter  is  smaller  than  two  and  nine-tenths 
inches,  it  is  not  well  to  delay  beyond  the  thirtieth  week.  The 
obstetrician  will  hope  that  by  the  induction  of  labor  the  head 
may  be  enabled  to  descend  through  the  brim  of  the  pelvis,  and 
the  labor  terminate  spontaneously.  When,  however,  he  is  called 
to  a  case  at  the  end  of  gestation,  in  which  he  finds  a  simple,  flat 
pelvis,  he  will  do  well  to  delay  only  until  dilatation  is  com- 
plete, and  opportunity  has  been  afforded  the  head  to  descend  by 
the  natural  forces  of  expulsion  through  the  brim  of  the  pelvis. 
Should  such  descent  not  occur  promptly,  podalic  version  should 
be  performed,  and  the  child  delivered  in  that  manner.  The  use 
of  the  forceps  in  simple,  flat  pelves  is  rarely  to  be  chosen,  as  the 
instrument  grasps  the  head  at  a  disadvantage,  and  injury  to  the 
mother  and  child  is  likely  to  result  (Fig.  86). 

A  rhachitic  pelvis  presents  not  only  contraction  in  the  antero- 
posterior  diameter  of  the  brim,  but  also  a  diminution  in  the 

FIG.  86. 


FLAT  PELVIS,  THE  HEAD  PASSING  THROUGH  AFTER  VERSION. 

transverse  diameters  of  the  pelvis.  It  will  be  remembered  that 
in  the  normal  pelvis  the  distance  between  the  anterior-superior 
spines  is  always  less  than  the  distance  between  the  outermost 
points  of  the  crests.  In  the  rhachitic  pelvis  this  relation  is 
either  lost  or  reversed.  The  upper  edges  of  the  ilia,  instead  of 
curving  downward  from  the  anterior-superior  spine,  extend  di- 


144 


MANUAL    OF    PRACTICAL   OBSTETRICS. 


rectly  backward,  or  even  curve  slightly  inward.    Upon  pelvimetry, 
the  obstetrician  will  find  the  antero-posterior  diameter  of  the  pelvis 

FIG.  87. 


FLAT  RHACHITIC  PELVIS. 

shortened,  the  transverse  diameters  contracted  as  indicated,  and 
not  infrequently  some  variation  on  closer  examination  in  the  ob- 

FIG.  88. 


FLAT  RHACHITIC  PELVIS. 


lique  measurements  of  the  pelvis  (Figs.  87  and  88).    In  addition  to 
these  diagnostic  points,  close  inspection  of  the  patient's  skeleton 


Plate  V. 


Davis'  Obstetrics. 


LABOR    IN    DEFORM  F.D    PELVES. 


FIG.  89. 


will  reveal  crooked  limbs,  enlargement  of  the  epiphyses  at  the  ex- 
tremities of  the  long  bones,  enlargement  of  the  costal  cartilages, 
producing  the  beaded  appearance  of  the  ribs  and  sternum,  with 
the  characteristic  deformity  of  the  cranium  and  face.  Labor  in 
such  pelves  will  be  difficult  in 
proportion  as  the  child  is  large, 
and  the  pelvis  greatly  de- 
formed. Here  again  the  same 
indications  for  the  induction 
of  labor  obtain  which  have  just 
been  stated  in  the  simple,  flat 
pelvis.  As  a  rule,  the  head 
will  enter  in  strong  flexion, 
and  should  the  child  be  small 
and  the  mother  strong,  the 
head  may  be  forced  down 
through  the  brim  of  the  pelvis 
upon  the  pelvic  floor.  Labor 
may  then  be  terminated  by  the 
careful  use  of  the  forceps. 
Should  the  head  engage,  the 
forceps  may  be  applied  at  the 
brim  of  the  pelvis,  and  axis- 
traction  performed  to  deliver 
the  child.  If  the  head  does 
not  engage,  but  after  labor- 
pains  have  become  well  estab- 
lished it  continues  to  remain 
at  the  brim  of  the  pelvis,  or 
passes  to  one  side  into  one  of 
the  iliac  fossae,  the  question  of 
craniotomy  or  the  Caesarean 
operation  must  be  raised  (Fig. 
89).  In  flat,  rhachitic  pelves,  no  advantage  will  be  obtained  by 
performing  podalic  version,  as  extension  of  the  head  would  pro- 
bably result  in  impaction  and  subsequent  death  of  the  foetus. 
7 


ATTITUDE  AND  ABDOMINAL  PROTRU- 
SION (PENDULOUS  ABDOMEN)  OF 
WOMAN  WITH  RHACHITIC  PELVIS. 


146  MANUAL   OF    PRACTICAL   OBSTETRICS. 

Rhachitis  may  be  found  in  combination  with  other  deformities  of 
the  pelvis,  resulting  in  irregularly  shaped  pelves,  giving  rise  to  vari- 
ous abnormalities  in  the  course  of  labor.  Thus,  projection  backward 
of  the  spinal  column  called  kyphosis  may  be  present,  causing  an 
enlargement  of  some  diameters  of  the  pelvis,  with  a  contraction  of 
others.  Again,  hip-joint  disease  in  a  rhachitic  person  would  result 
in  an  oblique  deformity  of  the  pelvis,  and  hence  a  diminution  in 
the  oblique  diameters.  These  mixed  deformities  of  the  pelvis  can 
best  be  appreciated  by  internal  palpation.  The  obstetrician,  finding 
that  the  measurements  obtained  by  external  pelvimetry  are  abnor- 
mal, will  then  have  recourse  to  an  internal  examination  of  the  pelvis. 
Two  or  three  fingers  should  be  introduced,  and  the  sides  of  the 
pelvis  thoroughly  examined.  Thus  a  contraction  at  the  brim  can 
be  estimated,  and  projection  inward  at  the  side  of  the  pelvis  will 
be  detected,  and  by  placing  a  finger  upon  each  tuberosity  of  the 
ischium  some  idea  may  be  gained  as  to  the  dimensions  of  the 
pelvic  outlet.  While  elaborate  instruments  have  been  devised 
for  such  examination,  none  has  been  found  so  efficient  as  the 
hand  of  an  intelligent  observer.  In  estimating  the  existence  of 
a  deformity  at  the  pelvic  outlet  during  labor,  the  practitioner  will 
find  it  of  value  to  examine  the  lateral  diameter  of  the  pelvis  at  a 
line  drawn  from  one  spine  of  the  ischia  to  the  other.  Should 
he  find  that  the  head  with  its  greatest  circumference  has  passed 
a  line  drawn  between  the  spines  of  the  ischia,  he  may  conclude 
that  no  contraction  sufficient  to  prevent  the  spontaneous  termi- 
nation of  labor  exists  at  the  pelvic  outlet. 

Spinal  deformities  are  not  infrequently  associated  with  rhachitis, 
and  may  delay  the  descent  of  the  foetus  into  the  pelvic  cavity.  A 
projection  forward  of  the  spinal  column  known  as  lordosis;  lateral 
curvature  of  the  spine  known  as  scoliosis,  kyphosis  already  men- 
tioned, and  a  peculiar  deformity  caused  by  a  partial  dislocation  of 
the  body  of  one  vertebra  upon  that  below,  with  a  lateral  twist  of 
the  vertebrae  called  spondylolisthesis,  may  prevent  descent  of  the 
body  of  the  foetus  or  cause  an  abnormality  in  its  presentation  or 
in  the  mechanism  of  labor  (Fig.  90).  Such  spinal  deformities, 
when  detected  during  pregnancy,  are  additional  indications  of  the 


Plate  VI. 


Davis'  Obstetrics. 


Flat  Rhachitic   Pelvis.     (Martin.) 


LABOR    IN    DEFORMED    PELVES.  147 

probable  existence  of  pelvic  deformity,  and  should  not  escape  the 
attention  of  the  obstetrician. 

While  the  simple,  flat  pelvis  and  the  rhachitis  pelvis  are  most 
common,  there  exist  comparatively  rare  forms  of  pelvic  deformity 
known  as  the  obliquely  contracted  pelvis  of  Naegele,  the  funnel- 
shaped  pelvis,  the  infantile  pelvis,  and  the  osteo-malacic  pelvis. 

FIG.  90. 


SrONDYLOLJSTHETIC    PELVIS. 

The  obliquely  contracted  pelvis  can  be  examined  by  measuring 
between  the  posterior  superior  spines  and  the  anterior  superior  of 
opposite  sides  (Fig.  91). 

The  funnel-shaped  pelvis  retains  somewhat  the  type  of  the 
male  pelvis  and,  as  its  name  implies,  is  longer  and  narrower  than 
the  normal. 

In  the  infantile  pelvis,  the  widening  and  expansion  character- 
istic of  the  normal  female  pelvis  have  not  occurred,  and  the  pelvis 
remains  practically  that  of  a  young  child. 

In  the  osteo-malacic  pelvis,  softening  of  the  bones  has  resulted 
in  the  bending  inward  of  the  anterior  half  of  the  pelvis,  bringing 
the  two  rami  of  the  pubes  almost  in  apposition  in  the  form  of  an  ir- 
regular beak  or  projection.  Other  indentations  of  the  pelvis  may 


148 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


result  from  osteo-malacia,  giving  rise  to  various  deformities.  It 
may  be  noted  that  the  disease  may  occur  during  pregnancy.  It 
is  characterized  by  severe  rheumatic-like  pains  in  the  pelvic 
bones,  by  great  prostration,  and  by  softening  which  becomes  evi- 
dent upon  careful  examination.  So  severe  may  be  these  symp- 
toms that  the  in- 

FlG-  9I-  terruption  of 

pregnancy  may 
be  necessary  to 
preserve  the  life 
of  the  mother. 
When  recovery 
takes  place  from 
osteo-malacia,  a 
process  of  thin- 
ning of  the  bones 
occurs  known  as 
osteo  -  p  o  r  o  s  i  s. 

OBLIQUELY  CONTRACTED  PELVIS  FOLLOWING  FRACTURE. 

comes     thinner, 

lighter  in  weight,  more  fragile  in  consistence.  On  the  other 
hand,  when  rhachitis  advances  but  slightly,  and  recovery  occurs 
during  early  life,  a  process  of  hardening  and  deposition  of  bony 
material  takes  place  which  is  styled  osteo-sclerosis. 

In  summarizing  the  indications  for  treatment  in  deformed  pel- 
ves, it  may  be  repeated  that  the  induction  of  labor  should  be  kept 
in  mind  in  cases  coming  under  the  care  of  the  obstetrician  before 
term.  As  pregnancy  progresses,  the  simple  manoeuvre  already 
described  of  pressing  the  head  into  the  pelvis  may  be  employed 
at  intervals  of  ten  days  or  two  weeks  to  give  some  idea  as  to  the 
time  when  the  induction  of  labor  is  necessary.  When  the  head 
will  not  engage  under  gentle  pressure,  pregnancy  should  be  in- 
terrupted. In  simple,  flat  pelves,  the  obstetrician  must  be  pre- 
pared to  terminate  labor  by  version.  In  flat,  rhachitic  pelves,  a 
cautious  use  of  the  forceps,  with  craniotomy  and  Cresarean  sec- 
tion to  be  kept  in  reserve,  is  indicated. 


CHAPTER    XXII. 

PREMATURE   LABOR. 

ABORTION  :  MISCARRIAGE. — In  a  considerable  proportion  of 
cases  pregnancy  is  terminated  before  its  usual  duration  has  ex- 
pired through  some  disease  or  accident.  It  has  been  customary 
to  designate  the  termination  of  pregnancy  before  the  formation 
of  the  placenta  at  the  fourth  month  as  abortion ;  between  the 
fourth  month  and  the  period  of  viability  at  the  seventh  month 
as  miscarriage;  and  between  the  seventh  month  and  ninth 
month  as  premature  labor ;  these  distinctions,  however,  are  with- 
out practical  differences,  and  the  simpler  way  is  to  consider  the 
interruption  of  pregnancy  before  the  period  of  viability  as  abor- 
tion, and  between  the  period  of  viability  and  the  usual  termina- 
tion of  pregnancy  as  premature  labor.  The  word  miscarriage  is 
less  objectionable  to  the  minds  of  patients  who  commonly  asso- 
ciate with  the  term  abortion  a  possible  criminal  element. 

The  causes  of  the  premature  termination  of  pregnancy  are  those 
which  affect  the  mother  or  the  ovum  or  both ;  most  common  of  all 
is  syphilis.  In  regard  to  the  conveyance  of  the  syphilitic  poison,  it 
is  possible  for  a  syphilitic  father  to  beget  syphilitic  children  with- 
out infecting  necessarily  the  mother ;  it  is  probably  impossible 
for  a  syphilitic  woman  to  bear  a  child  not  tainted  by  syphilis ; 
when  father  and  mother  are  both  syphilitic  the  offspring  present 
unmistakable  evidences  of  syphilis.  Diseases  which  affect  the 
general  health  of  the  mother  also  interrupt  pregnancy ;  acute  in- 
fections causing  high  temperature  commonly  interrupt  pregnancy 
when  the  temperature  remains  above  104°  F.  for  a  considerable 
time.  Chronic  infections,  such  as,  in  addition  to  syphilis,  mal- 
aria, lead  poisoning,  and  alcoholism  cause  abortion. 

Diseases  affecting  the  foetus  and  its  envelopes  also  terminate  its 

149 


150  MANUAL    OF    PRACTICAL    OBSTETRICS. 

existence ;  such  are  dropsy  of  the  chorion,  adhesion  between  the 
layers  of  the  aninion  and  the  abnormal  secretion  of  amnial  liquid. 
Violence  may  affect  the  mother  and  ovum  by  separating  the  latter 
from  the  wall  of  the  uterus  by  rupturing  the  membranes,  or  by  its 
influence  upon  the  nervous  system  producing  uterine  contractions ; 
the  effect  of  mechanical  violence  depends,  however,  largely  upon 
the  condition  of  the  mother's  tissues  ;  where  the  woman  has  never 
had  endometritis  and  her  tissues  are  in  a  healthy  condition,  she 
may  sustain  a  very  considerable  degree  of  direct  mechanical  vio- 
lence without  the  occurrence  of  abortion ;  persistent  disturbance 
is  often  more  dangerous  than  a  considerable  shock ;  thus  the  jar 
of  a  railway  train  will  sometimes  produce  disaster,  when  a  fall  of 
several  feet  will  not.  That  which  tends  to  increase  irritability  of 
the  nervous  system  also  results  in  the  interruption  of  pregnancy, 
and  when  once  this  condition  of  exaggerated  reflexes  exists  the 
slightest  cause  may  produce  an  interruption  of  pregnancy. 

The  symptoms  of  a  threatened  termination  of  pregnancy  are  ab- 
dominal pain  and  hemorrhage;  the  pain  is  caused  by  the  contrac- 
tion of  the  uterus,  and  hence  is  to  be  distinguished  from  intestinal 
colic,  neuralgia  of  the  solar  plexus,  acute  dyspepsia,  or  the  suffer- 
ing caused  by  a  distended  bladder ;  the  hemorrhage  is  bright  in 
color,  and  varying  in  quantity ;  should  the  process  go  on,  further 
symptoms  are  an  increase  in  the  hemorrhage,  with  the  discharge 
of  portions  of  the  ovum  or  the  ovum  entire.  The  interruption 
of  pregnancy  is  most  common  between  the  third  and  fourth 
month,  and  at  any  period  of  pregnancy  when  menstruation  should 
have  occurred  if  conception  had  not  taken  place. 

The  treatment  of  abortion  and  premature  labor  consists,  first, 
in  prophylaxis  ;  if  syphilis  exists,  the  patient  should  be  treated  by 
the  administration  of  the  bin-iodide  or  bi-chloride  of  mercury, 
together  with  cod-liver  oil,  hypophosphites,  iron  and  arsenic  ;  it 
is  to  be  remembered  that  the  treatment  of  syphilis  demands  not 
only  the  use  of  alteratives  but  also  the  employment  of  those 
agents  which  will  most  effectively  favor  the  reproduction  of  the 
blood.  During  acute  diseases  but  little  can  be  done  to  prevent 
the  interruption  of  pregnancy  beyond  that  which  is  indicated  in 


PREMATURE   LABOR.  151 

the  mother's  interest  only ;  it  is  well  to  control  if  possible  the 
patient's  fever  and  lessen  the  irritability  of  her  nervous  system ; 
conditions  of  chronic  infection  are  to  be  remedied  by  appropri- 
ate treatment  which  is  most  advantageously  employed  when  the 
patient  is  not  pregnant. 

By  the  habit  of  abortion  is  understood  the  recurrence  of  this 
accident ;  when  the  cause  is  found  and  removed  the  habit  is 
broken.  In  cases  which  present  no  easily  found  cause  for  abor- 
tion it  is  well  first  to  see  that  the  patient  is  not  suffering  from 
chronic  endometritis ;  should  such  be  the  case,  dilatation  of  the 
uterus  followed  by  the  application  of  antiseptic  and  alterative 
substances  to  the  endometrium,  and  often  the  removal  of  the 
diseased  tissue  by  the  curette  may  be  followed  by  conception. 
When  no  cause  other  than  excessive  irritability  be  found,  it  is 
sometimes  necessary  to  place  the  patient  entirely  at  rest  until  her 
pregnancy  be  several  months  advanced ;  actual  confinement  to 
her  bed  is  the  only  successful  treatment  for  such  a  condition :  her 
health,  in  the  meantime,  should  be  maintained  by  massage  and 
attention  to  her  nutrition.  When  abortion  has  actually  begun 
absolute  rest  is  imperative  ;  usually  opium  will  be  found  the  best 
drug  to  allay  the  activity  of  the  nervous  system ;  the  patient  should 
abstain  from  all  kinds  of  stimulants,  should  remain  lightly  clad, 
and  avoid  heating  and  stimulating  food  (Fig.  92). 

Should  the  physician  fail  in  his  efforts  to  check  the  premature 
expulsion  of  the  ovum,  his  treatment  should  be  addressed  to 
securing  its  expulsion  entire;  in  cases  occurring  prior  to  the 
fourth  month  this  can  best  be  done  by  controlling  the  hemor- 
rhage with  an  antiseptic  tampon  and  stimulating  uterine  contrac- 
tions; as  material  for  the  tampon,  iodoform  gauze,  bi-chloride  of 
mercury  gauze,  or  masses  of  cotton  impregnated  with  an  antisep- 
tic may  be  employed.  Where  the  odor  of  iodoform  is  not  objec- 
tionable, iodoform  gauze  should  be  chosen;  in  the  absence  of 
gauze,  cheese  cloth  soaked  in  a  solution  of  bi-chloride  of  mercury, 
one  to  five  thousand  will  answer ;  failing  to  obtain  cheese  cloth, 
an  ordinary  roller  bandage  or  a  strip  of  old  sheeting  will  serve 
every  purpose ;  if  the  assistance  of  a  nurse  is  available  it  is  well  to 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


FIG.  92. 


have  the  patient  given  a  hot  antiseptic  vaginal  douche ;  following 
this  she  is  placed  across  a  bed  at  the  edge;  introducing  one  or  two 
fingers  of  one  hand  as  a  guide,  the  physician  takes  the  end  of  the 
strip  of  tampon,  and,  with  a  pair  of  dressing  forceps,  passes  it  up, 
and  with  the  finger  packs  it  thoroughly  into  the  os  and  cervix, 
and  around  these  parts;  the  vagina  may  also  be  moderately  dis- 
tended with  the  same  material;  the  administration  of  ergot  in 

medium  doses,  fifteen  to  thirty 
drops  of  the  fluid  extract  every 
two  or  three  hours,  combined  with 
the  administration  of  quinine  in 
debilitated  patients,  is  also  indi- 
cated. Under  such  treatment  it 
is  usual,  after  from  six  to  twelve 
hours,  for  the  physician  to  find 
the  ovum  in  the  upper  portion  of 
the  vagina  upon  removing  the 
tampon ;  he  may  find  it  just  within 
the  os,  whence  he  should  remove 
it  cautiously  with  the  finger;  after 
its  expulsion  a  hot  vaginal  douche 
should  be  given,  and  if  the  fingers 
or  any  instrument  have  entered 
tot  and  nip-  the  uterus,  an  intra-uterine  douche 

tured  vessels.       i         t  j  r          j      •     •    .          j 

should  be  administered. 

Should  the  ovum  rupture,  and 
a  portion  be  retained,  the  uterus 
should  be  explored  as  soon  as 
possible  by  the  antisepticized  fin- 
ger of  the  obstetrician  and  its  contents  removed ;  if  sufficient  dila- 
tation is  not  present  to  permit  of  this  manipulation,  Barnes' 
dilators,  or  a  solid  uterine  dilator,  such  as  Simons',  may  be  em- 
ployed; and  if  the  cervix  is  found  resisting,  a  tupelo,  or  slippery- 
elm  tent  should  be  used  (Fig.  93).  Next  to  the  finger  as  an 
instrument  for  emptying  the  uterus  after  abortion,  stands  the 
intra-uterine  curette ;  of  these  our  preference,  from  experience, 


OVUM  OF  TWO  MONTHS,  INTACT. 


PREMATURE    LABOR. 


153 


is  for  that  of  Carl  Braun,  which  has  a  long,  hollow  handle  termi- 
nating in  a  blade  whose  edge  is  as  sharp  as  that  of  a  paper-knife; 
this  handle  is  connected  with  a  fountain  syringe,  and  thus  a  con- 
stant stream  of  antiseptic  fluid  irrigates  the  uterine  wall  while 
the  curette  removes  retained  material ;  after  the  uterus  has  been 
emptied  and  cleansed,  it  is  well  to  leave  within  its  cavity  sixty 

FIG.  93. 


SAME  OVUM,  THE  DECIDUOUS  MEMBRANES  OPENED, 
SHOWING  VlLLI  OF  CHORION. 

grains  of  iodoform,  aristol,  or  boracic  acid  in  the  form  of  a  sup- 
pository. In  view  of  the  fact  that  portions  of  the  ovum  are  often 
retained  and  spontaneously  expelled  without  serious  consequences 
to  the  patient,  such  thorough  precautions  may  seem  meddlesome 
and  injudicious,  but  the  number  of  cases  of  septicaemia  which 
follow  abortion  is  sufficiently  great  to  warrant  the  obstetrician 
who  desires  to  do  his  duty  in  not  leaving  his  patient  until  he  is 
satisfied  that  her  genital  tract  has  been  thoroughly  antisepticized. 


154  MANUAL   OF   PRACTICAL   OBSTETRICS. 

The  treatment  of  abortion  after  the  fifth  month  resembles  that 
of  normal  labor,  except  that  de.lay  may  occur  in  the  dilatation  of 
the  os  and  cervix,  and  difficulty  may  be  experienced  in  aiding 
the  expulsion  of  the  foetus;  as  the  uterus  is  not  fully  prepared  for 
labor,  deficient  expulsive  pains  are  not  uncommon.  Although  the 
foetus  may  present  by  the  head,  it  will  be  better  in  such  cases  to 
perform  version  and  extraction  by  the  feet,  as  the  forceps  is  not 
always  successful  in  grasping  securely  the  head  of  a  premature 
foetus.  It  is  in  cases  of  this  sort  that  adherent  placenta  is  most 
often  encountered,  although  fn  the  minds  of  patients  and  their 
friends  the  placenta  is  thought  to  be  adherent  when  it  is  not 
promptly  expelled.  The  obstetrician  will  recall  the  fact  that 
adherent  placenta  is  not  a  frequent  complication,  while  tempo- 
rary retention  of  the  placenta  occurs  quite  frequently.  In  cases 
where  the  placenta  is  attached  to  the  uterine  wall  so  firmly  that 
uterine  contractions  do  not  separate  it,  a  cautious  attempt  should 
be  made  by  the  obstetrician  to  separate  and  remove  it  with  his 
hand ;  the  greatest  care  should  be  exercised  not  to  wound  the 
uterine  tissue  any  more  than  can  possibly  be  avoided,  and,  rather 
than  do  violence,  it  is  better  to  allow  the  placenta  to  remain,  after 
antisepticizing  the  uterus,  and  keep  the  patient  under  observation 
until  the  placenta  shall  have  become  loosened,  when  it  can  be 
safely  extracted.  During  this  time,  until  the  placenta  can  be  re- 
moved, four  vaginal  douches  of  bi-chloride  of  mercury,  one  to 
five  thousand,  should  be  given  in  twenty-four  hours ;  the  uterus 
should  be  irrigated  twice  in  twenty- four  hours  with  carbolic  acid, 
creolin,  thymol  or  boracic  acid,  as  has  been  elsewhere  described ; 
the  local  disinfection  of  the  uterus  should  be  maintained  by 
iodoform,  aristol  or  boracic  acid,  by  uterine  suppositories,  and 
an  antiseptic  tampon  can  often  be  kept  within  the  uterus  to 
advantage.  Under  such  precautions  it  is  safe  to  wait  for  the 
loosening  and  expulsion  of  the  placenta  without  radical  interfer- 
ence ;  but  under  less  careful  precautions  it  is  hazardous  to  do  so ; 
the  curette  is  of  advantage  in  such  cases  after  the  placenta  has 
become  loosened  and  small  fragments  still  remain  which  do  not 
admit  of  easy  removal  by  the  finger. 


PREMATURE   LABOR.  155 

Abortion  is  also  divided  into  therapeutic  and  criminal ;  by 
therapeutic  abortion  is  understood  the  intentional  interruption  of 
pregnancy  by  the  obstetrician  in  the  interests  of  the  mother ; 
pernicious  vomiting,  toxaemia,  threatening  eclampsia,  and  some 
obstruction  in  the  mother's  birth-canal  are  the  most  frequent 
indications ;  the  method  best  chosen  in  these  cases  consists  in  the 
dilatation  of  the  uterus  by  tents,  by  solid  dilators,  or  the  Barnes' 
bag,  with  the  removal  of  the  ovum,  as  has  just  been  described.  In 
cases  where  pregnancy  is  further  advanced,  a  bougie  may  be  intro- 
duced into  the  uterus  between  the  membranes  and  the  wall  of  the 
uterus,  and  allowed  to  remain  until  expelled  by  uterine  contrac- 
tion. In  very  early  pregnancy  the  introduction  of  a  sound  into 
the  uterus  may  rupture  the  ovum,  when  it  may  be  absorbed  with- 
out danger  to  the  patient.  Her  safety,  however,  in  all  these  pro- 
cedures depends  very  largely  upon  the  careful  antisepsis  practiced 
by  the  physician,  and  in  general  it  may  be  stated  that  that 
method  of  producing  abortion  is  best  which  is  most  sure  to  do 
little  violence  to  the  mother's  uterus,  and  leave  it  entirely 
empty. 

By  criminal  abortion  is  understood  the  interruption  of  preg- 
nancy without  justification ;  this  is  commonly  practiced  by  the 
administration  of  drugs  supposed  to  produce  uterine  contractions  ; 
such  are  tansy,  nutmeg,  ginger,  cantharides,  and  a  number  of 
patent  medicines  whose  active  principle  is  usually  ergot  or  quinine. 
It  is  extremely  doubtful  in  healthy  women  whether  any  of  these 
drugs  are  capable  of  producing  the  desired  effect ;  they  are 
certainly  far  from  being  reliable  ;  failing  to  produce  abortion 
with  these  means,  the  patient  usually  seeks  the  assistance  of  an 
accomplice ;  the  injection  of  hot  or  cold  water  into  the  vagina, 
and  the  introduction  into  the  uterus  of  a  foreign  body,  are  the 
most  usual  methods  employed  ;  splinters  of  wood,  hair-pins,  pieces 
of  whalebone,  pieces  of  wire,  and  various  articles  have  been  used 
for  this  purpose. 

Those  who  practice  abortion  are  usually  ignorant  of  antiseptic 
precautions,  and  hence  septic  infection  following  criminal  abortion, 
with  death  from  septicaemia  and  peritonitis,  are  not  uncommon; 


156  MANUAL    OF    PRACTICAL    OBSTETRICS. 

electricity  has  been  tried  to  produce  abortion,  occasionally  with 
success,  often  with  failure. 

Diagnostic  signs  of  criminal  abortion,  either  attempted  or 
successful,  are  signs  of  early  pregnancy  with  some  evidence  that 
injury  has  been  done  to  the  genital  tract;  when  such  evidence 
is  presented,  the  physician  called  to  care  for  such  a  patient  should 
remember  the  danger  of  septic  infection  and  endeavor  to  counter- 
act it,  while  co-operating  with  the  authorities  to  bring  the  offender 
to  justice. 


CHAPTER    XXIII. 

INDUCED  LABOR. 

WHENEVER  the  interests  of  mother  or  child  demand  the  termi- 
nation of  labor  after  the  child  is  viable,  but  without  waiting  for 
the  forces  of  Nature  to  produce  spontaneous  labor,  the  artificial 
ending  of  gestation  is  known  as  induced  labor.  The  indications 
for  this  procedure  are  diseases  seriously  threatening  the  life  of  the 
mother,  a  contracted  condition  of  the  birth-canal,  making  it 
dangerous  for  delivery  to  take  place  when  the  child  is  at  term, 
and  any  condition  of  the  foetus  rendering  its  death  probable  if  it 
be  allowed  to  remain  in  the  uterus. 

Among  the  maternal  indications  for  induced  labor  are  such 
diseases  of  the  mother  as  result  in  pathological  changes  in  the 
endometrium  and  placenta,  rendering  the  life  of  the  child  impos- 
sible after  a  certain  period  of  pregnancy.  This  may  be  well 
illustrated  by  chronic  nephritis  occurring  during  pregnancy. 
Whenever  the  obstetrician  detects  habitually  in  the  urine  of  the 
pregnant  woman  various  forms  of  tube-casts,  with  or  without 
albumin,  and  this  condition  persists,  he  will  know  that  the  exist- 
ence of  the  foetus  is  jeopardized,  and  that  labor  should  be  induced 
when  viability  is  assured.  A  distinction  should  be  made  between 
acute  and  chronic  disease  processes  in  the  mother  as  regards  the 
interruption  of  pregnancy.  In  acute  infectious  diseases,  the 
course  of  the  disease  is  usually  influenced  unfavorably  by  any 
effort  to  terminate  the  pregnancy,  while  in  many  chronic  con- 
ditions the  induction  of  labor  greatly  relieves  the  patient.  The 
death  of  the  foetus  furnishes  an  indication  for  the  induction  of 
labor,  and  also  any  history  of  complications  occurring  during 
previous  pregnancies,  or  at  previous  labors,  threatening  the  lives 
of  mother  and  child. 

In  so  far  as  contraction  of  the  birth-canal  is  an  indication  for 
the  induction  of  labor,  this  will  evidently  depend  upon  a  com- 

'57 


158  MANUAL   OF    PRACTICAL   OBSTETRICS. 

parison  instituted  between  the  size  of  the  child  arid  that  of  the 
birth-canal,  as  has  been  already  described.  In  the  section  upon 
labor  in  contracted  pelves,  this  point  has  been  discussed,  and 
also  the  precise  periods  of  pregnancy  at  which  interruption  was 
justified.  In  general,  it  may  be  stated  that  when  upon  examina- 
tion of  a  pregnant  woman  the  antero-posterior  diameter  at  the 
brim  of  the  pelvis  is  found  to  measure  but  eight  centimetres,  or 
three  and  one-eighth  inches,  the  question  of  the  induction  of 
labor  should  be  seriously  considered. 

The  methods  of  inducing  labor  consist  in  efforts  by  various 
means  to  cause  uterine  contraction.  These  efforts  have  been 
made  by  directly  irritating  the  uterus,  as  with  an  electric  cur- 
rent, with  dilators  or  a  bougie;  also  by  the  giving  of  some  drug 
acting  upon  the  uterine  muscle  and  causing  contraction,  or  by 
disturbing  the  relations  of  the  foetus  and  the  uterus  by  evacu- 
ating the  amniotic  liquid,  thus  allowing  the  child  itself  to  make 
pressure  against  the  wall  of  the  uterus  and  excite  contraction. 

To  specify  more  clearly,  the  induction  of  labor  has  been  at- 
tempted by  the  use  of  a  strong  faradic  current,  one  pole  being 
placed  above  the  pubes,  the  other  upon  the  lumbar  spine.  Ef- 
forts have  been  made  to  secure  uterine  contractions  by  rubbing 
or  kneading  the  uterus,  and  also  by  hot  douches.  Barnes'  dila- 
tors and  tents  of  various  sorts  have  also  been  introduced  to  dilate 
the  cervix  and  promote  uterine  contractions.  Water  has  been 
injected  into  the  uterus  between  the  membranes  and  the  wall  of 
the  womb,  to  cause  uterine  contractions.  Drugs  whose  proper- 
ties are  to  irritate  and  excite  the  uterine  muscle  have  also  been 
given,  such  as  ergot,  tansy,  quinine,  strychnine  and  some  of  the 
volatile  oils.  The  membranes  have  also  been  ruptured,  a  portion 
of  the  amniotic  liquid  allowed  to  escape,  and  the  head  brought 
directly  against  the  os  and  cervix,  thus  exciting  uterine  contrac- 
tions ;  but  the  best  and  safest  of  all  methods  consists  in  intro- 
ducing within  the  uterus,  between  the  membranes  and  the  wall  of 
the  womb,  a  flexible  rod  or  bougie.  This  acts  as  a  foreign  body 
whose  irritation  rarely  fails  to  bring  on  labor.  Second  in  effi- 
ciency and  value  to  this  is  the  use  of  Barnes'  dilators.  In  intro- 


INDUCED   LABOR. 


'59 


ducing  a  bougie,  one  should  be  selected  which  is  solid,  and 
which  has  never  been  used  before.  A  medium  size  should  be 
chosen,  and  care  should  be  taken  that  the  bougie  has  not  been 
corroded  or  roughened  in  any  manner.  It  should  be  immersed 
for  some  time  in  a  solution  of  bichloride  of  mercury  one  to  five 
hundred,  after  which  it  may  be  kept  in  a  mercurial  solution  one 
to  two  thousand,  or  in  a  carbolic  solution  five  per  cent.,  until  it 
is  used.  If  convenient,  a  vaginal  douche  should  be  given  before 
the  introduction  of  the  bougie.  The  greatest  care  should  be 
exercised  by  the  obstetrician  in  cleansing  his  hands  and  in 
avoiding  contact  between  the  bougie  and  the  bedding  of  the 
patient  while  introducing  it.  Two  fingers  of  one  hand  are 
then  inserted  to  the  cervix,  and  the  bougie  passed  along  these 
fingers  as  a  guide  through  the  os.  No  force  should  be  used  in 
introduction;  but  it  should  be  allowed  to  go  where  it  will  pass 
most  easily,  care  being  taken  to  avoid  rupturing  the  membranes. 
The  bougie  should  be  inserted  until  but  an  inch  of  its  length 
remains  outside  the  cervix.  If  it  shows  a  tendency  to  slip  out 
easily,  a  moderate  tampon  of  iodoform  gauze  should  be  inserted 
to  retain  it  in  position. 

A  bougie  may  be  conveniently  inserted  during  the  afternoon 
or  evening.  Intermittent  uterine  contractions  causing  dilatation 
will  usually  continue  during  the  night.  In  the  morning,  it  will 
be  found  upon  examination  that  softening  and  dilatation  of 
the  os  and  cervix  have  resulted.  The  bougie  should  then  be 
removed,  an  antiseptic  douche  be  given,  and  the  first  bougie  with 
a  second  in  addition  should  be  introduced.  The  number  may 
be  increased  until  several  are  employed  at  once.  The  length  of 
time,  required  to  bring  on  active  uterine  contractions  by  this 
method  varies  greatly.  Forty-eight  hours  will  usually  suffice  to 
cause  active  labor,  but  in  a  case  in  the  experience  of  the  writer, 
bougies  remained  in  the  uterus  between  five  and  six  days  before 
labor  came  on.  If  antiseptic  precautions  be  faithfully  observed, 
and  the  membranes  be  not  ruptured,  no  harm  will  come  to  the 
patient  from  a  prolonged  use  of  this  method. 

The  employment  of  a  Barnes'  dilator  to  induce  labor  is  indicated 


l6o  MANUAL    OF    PRACTICAL    OBSTETRICS. 

in  cases  where  the  os  and  cervix  are  already  sufficiently  large  to 
admit  of  its  introduction,  and  where  it  is  desired  to  dilate  the  ute- 
rus and  terminate  labor  as  speedily  as  possible.  The  obstetrician 
should  provide  himself  with  several  sizes  of  dilators  whose  capacity 
he  ascertains  before  using  them.  A  dilator  should  be  slightly  oiled, 
and  introduced  well  into  the  cervix.  An  antiseptic  solution  is  then 
forced  into  the  dilator  until  considerable  distension  and  the  firm 
application  of  the  dilator  to  the  sides  of  the  cervix  have  been  se- 
cured. If  the  capacity  of  each  Barnes'  bag  is  known  by  the  ob- 
stetrician, little  danger  will  exist  of  rupturing  the  dilator  and  forcing 
fluid  into  the  uterine  cavity.  The  use  of  an  antiseptic  fluid  reduces 
the  risk  from  this  accident  to  a  minimum.  It  will  usually  be  found 
in  between  one  and  two  hours  that  the  dilator  has  accomplished  its 
mission,  and  that  a  second  and  larger  is  required.  In  from  four  to 
eight  hours  the  uterus  may  be  so  dilated  by  this  method  that  the 
application  of  forceps,  or  performance  of  version,  will  be  possible. 
When  induced  labor  has  fairly  begun,  it  should  be  remembered 
that  the  patient  has  greater  difficulties  than  usual  to  overcome. 
The  physiological  softening  and  dilatation  of  the  birth-canal 
which  occur  at  normal  labors  are  rarely  present  to  the  same  de- 
gree. Induced  labor  may  then  be  longer,  more  painful,  and 
more  exhausting.  On  the  other  hand,  the  fact  that  the  child  is 
smaller  than  in  labor  at  term  will  prove  an  advantage  at  the  time 
of  delivery.  Every  precaution  should  be  taken  to  maintain  an 
aseptic  condition  of  the  patient  because  her  liabilities  to  infection 
by  reason  of  the  interference  practised  are  greater  than  in  normal 
cases.  When  labor  is  induced  by  the  use  of  the  bougie  or  Barnes' 
dilators,  morbidity  and  mortality  rates  of  the  mother  should  not 
be  higher  under  antiseptic  precautions  than  normal.  The  dangers 
to  the  child  are  greater  than  usual  because  of  the  possible  failure  in 
dilatation  and  also  because  of  the  necessity  often  arising  of  oper- 
ative interference  in  the  delivery.  If  induced  labor  be  delayed, 
the  child  will  frequently  perish  from  pressure  of  the  uterus  upon 
it,  or  from  inspiration  pneumonia  coming  on  shortly  after  deliv- 
ery, and  occasioned  by  the  entrance  of  the  secretions  from  the 
vagina  into  the  respiratory  passages  as  labor  progresses. 


CHAPTER   XXIV. 

MULTIPLE    PREGNANCY. 

WHEN  the  genital  tract  of  the  woman  contains  more  than  one 
impregnated  ovum  the  pregnancy  is  multiple  or  plural.  Usually 
the  ova  find  lodgement  and  develope  in  the  uterus ;  occasionally 
one  developes  in  the  uterus  and  one  in  the  Fallopian  tube  ;  rare- 
ly there  is  multiple  ectopic  pregnancy.  When  there  are  two  ova 
the  pregnancy  is  said  to  be  with  twins ;  when  three,  triplets ; 
with  four,  quadruplets;  with  five,  quintriplets ;  with  six,  sextup- 
lets.  One  authentic  case  of  miscarriage  with  six  foetuses  is  re- 
corded as  having  occurred  in  Italian  Switzerland,  the  greatest 
number  on  record.  Twins  occur  on  an  average  about  once  in 
too  cases;  triplets,  once  in  8,000;  quadruplets,  once  in  400,000. 
These  averages  vary  greatly  in  different  races  and  countries. 

Two  terms  are  used  to  express  the  impregnation  of  more  than 
one  ovum,  Superfecundation  and  Superfoetation.  Superfecunda- 
tion  refers  to  the  successive  impregnation  of  several  ova  before  an 
impregnated  ovum  has  reached  the  uterus  and  before  a  second 
ovulation.  This  is  observed  in  cases  when  twins  are  born  of  dif- 
ferent parentage,  one  black,  the  other  a  light  mulatto.  It  has 
also  been  seen  in  cases  where  two  ova  of  the  same  parentage  have 
been  found  at  different  stages  of  development,  one  in  the  uterus, 
the  other  in  some  other  portion  of  the  genital  tract.  These  cases 
are  explicable  by  successive  coitions  by  the  same  or  different 
fathers. 

Superfcetation  refers  to  the  impregnation  of  a  second  ovum 
when  the  first  has  already  advanced  several  weeks  and  has 
reached  the  uterine  cavity.  A  second  ovulation,  after  the  first 
impregnation,  would  seem  necessary  to  explain  superfoetation. 

7*  161 


1 62  MANUAL    OF    PRACTICAL    OBSTETRICS. 

Superfecundation  occurs  not  infrequently;  superfcetation  cannot 
occur  after  the  ovular  and  uterine  decidua  join,  in  the  fourth 
month,  and  probably  rarely  takes  place  before. 

Twins  are  most  often  of  similar  sex,  and  more  frequently  boys. 
When  of  the  same  sex  they  often  resemble  each  other  very 
closely  in  physical  and  mental  characteristics.  They  are  rarely 
of  precisely  the  same  weight,  although  their  combined  weight 
exceeds  that  of  a  single  foetus.  The  amnion  and  chorion  of  one 
ovum  are  not  infrequently  observed  to  take  up  considerable  space 
on  the  foetal  surface  of  the  placenta  of  the  other  ovum.  De- 
creased nutrition  in  the  second  ovum  results.  Five-sevenths  of 
all  cases  of  twins  have  but  one  placenta,  this  fact  furnishing  an 
argument  against  superfoetation.  When  the  sex  is  the  same  there 
is  one  placenta,  with  one  chorion  and  two  amnions.  When  the 
sex  is  unlike  it  is  not  infrequent  to  find  two  chorions  and  two 
amaions  with  one  placenta,  both  ova  having  been  derived  from  a 
single  follicle.  There  is  then  no  vascular  connection,  each 
ovum  having  a  separate  blood  supply.  In  twins  and  triplets 
which  develope  from  one  ovum,  a  circulation  by  means  of  villi 
has  been  found,  forming  a  third  blood  system  by  which  the  same 
blood  passes  through  both  foetal  hearts. 

Repeated  pregnancies  and  hereditary  tendency  to  multiple 
pregnancy  are  the  chief  causes  of  multiple  pregnancy.  The  diag- 
nosis of  more  than  one  foetus  is  possible  only  by  careful  attention 
to  the  details  of  diagnosis  by  palpation  and  auscultation.  Wo- 
men pregnant  with  more  than  one  foetus  have  naturally  larger 
abdomens,  are  more  liable  to  suffer  from  varicose  veins  and 
oedema,  and  often  experience  greater  discomfort  than  in  single 
pregnancy.  When  the  abdomen  is  examined  and  two  fcetal 
heart- sounds  in  distinctly  different  areas  can  be  heard,  and  three 
greater  foetal  parts,  one  head  and  two  breeches,  or  two  heads  and 
one  breech,  can  be  plainly  outlined,  a  diagnosis  of  multiple  preg- 
nancy may  be  made.  The  patient's  impressions,  and  any  less 
positive  data,  are  worthless  in  forming  an  opinion.  At  the  time 
of  labor,  when  the  uterus  remains  large,  after  the  birth  of  one 
child,  and  when  a  second  can  be  felt  on  vaginal  examination, 


MULTIPLE    PREGNANCY.  163 

twins  may  be  diagnosticated.  The  possibility  of  twin  pregnancy 
has  led  to  the  invariable  custom,  with  careful  obstetricians,  of 
ligating  the  placental  extremity  of  the  umbilical  cord,  at  labor, 
to  prevent  haemorrhage  from  the  placenta.  The  diagnosis  of 
multiple  pregnancy  is  not  often  easily  made,  and  a  positive  opin- 
ion should  not  be  given  without  evidence  afforded  by  thorough 
examination. 

Pregnancy  rarely  goes  to  full  term  when  more  than  one  foetus 
is  present.  The  over-distended  condition  of  the  uterus  renders 
it  more  than  usually  sensitive  to  reflex  irritation,  and  labor  pains 
are  easily  excited.  Abnormalities  in  the  membranes  and  pla- 
centae and  polyhydramnios  are  often  present  in  multiple  preg- 
nancy. One  foetus  not  rarely  kills  the  other  by  pressing  it  against 
the  uterine  wall,  the  foetus  which  perishes  becoming  flattened, 
thinned  and  shriveled,  hence  called  foetus  papyraceus  or  parche- 
ment-like  foetus.  Monsters  without  heads,  acephalous  monsters, 
occur  in  multiple  pregnancies. 

The  position  and  attitude  of  the  foetuses  in  twin  pregnancies 
are  usually  one  presenting  by  the  head,  the  other  by  the  breech. 
Less  often  both  present  by  the  breech  or  head.  Labor  in  multi- 
ple pregnancies  is  slow  in  the  first  stage,  because  the  cervix 
dilates  slowly  and  the  lower  uterine  segment  is  not  readily 
formed.  The  second  stage  is  often  short,  the  small  size  of  the 
children  rendering  their  expulsion  easy.  In  the  third  stage  the 
over-distended  uterus  may  contract  imperfectly  and  placental 
retention  and  post-partum  haemorrhage  are  not  infrequent.  If 
the  position  of  both  twins  is  not  favorable  for  prompt  expulsion, 
the  imperfect  dilatation  of  the  cervix  and  lower  uterine  segment 
threaten  the  life  of  the  second  twin  by  pressure. 

In  conducting  twin  labor  the  obstetrician  should  be  prepared 
to  deliver  the  second  twin  promptly  if  there  is  but  one  foetal  sac ; 
where  there  are  two  and  the  second  is  unruptured  after  the  birth 
of  the  first  twin,  there  is  less  need  of  prompt  delivery.  Twins 
may  become  so  intertwined  that  spontaneous  delivery  is  impos- 
sible ;  uterine  contractions  continuing  and  retraction  of  the  upper 
uterine  segment  taking  place,  the  twins  become  firmly  fixed,  and 


164  MANUAL   OF    PRACTICAL   OBSTETRICS. 

in  their  abnormal  position  are  said  to  be  "locked."  When  one 
twin  presents  by  the  head  and  the  other  by  the  breech,  the  body 
of  the  first  (breech  presenting)  twin  may  be  expelled ;  both 
heads  enter  the  pelvic  cavity  at  once,  the  first  head  is  in  exten- 
sion, the  second  flexes,  and  the  chin  of  the  first  and  occiput  of 
the  second  become  wedged  into  the  pelvic  brim.  A  similar  im- 
paction  may  result  when  both  heads  present.  When  the  mother's 
pelvis  is  lar^e,  the  amniotic  fluid  abundant  and  the  membranes 
rupture  suddenly  while  the  patient  is  erect,  prolapse  of  foetal 
limbs  and  cords  may  result.  Transverse  position  of  one  twin 
may  also  occur. 

The  diagnosis  of  multiple  pregnancy  is  often  made  for  the  first 
time  after  the  birth  of  the  first  foetus.  If  the  physician's  suspi- 
cions are  aroused  he  should  at  once  make  a  thorough  examina- 
tion, if  necessary  introducing  the  greater  portion  of  the  antisep- 
ticized  hand.  If  the  second  foetal  sac  is  unruptured,  good  uter- 
ine contractions  should  be  secured  by  gentle  friction  and  labor 
will  proceed  spontaneously.  If  the  sac  of  the  second  foetus  has 
ruptured  and  the  second  twin  is  not  born  promptly,  the  forceps 
may  be  applied  if  the  vertex  presents ;  if  the  face  presents  or  the 
shoulder,  immediate  version  is  indicated,  with  extraction  by  the 
breech. 

In  complicated  presentation  and  prolapse  of  the  lirnbs  and 
cords,  the  antisepticized  hand,  introduced  under  complete  anaes- 
thesia by  chloroform,  is  the  most  speedy  and  certain  instrument. 
In  locked  twins,  the  first  precaution  must  be  to  determine  the 
condition  of  the  uterine  muscle.  If  the  contraction  be  found 
high  in  the  abdomen,  uterine  tetanus  being  present,  the  patient 
should  be  completely  anaesthetized  by  chloroform,  and  a  catheter 
having  been  passed  and  the  bladder  emptied,  a  cautious  attempt 
should  be  made  to  dislodge  impacted  parts.  Only  the  most 
gentle  manipulation  is  permissible,  as  uterine  rupture  is  easily 
produced.  Failing  in  this,  the  physician  must  perform  embry- 
otomy  on  the  first  twin  in  the  interests  of  the  second.  The  cir- 
cumstances of  the  case  and  the  operator's  judgment  will  deter- 
mine just  what  procedure  is  best.  We  have  succeeded  in  a 


MULTIPLE    PREGNANCY.  165 

difficult  case  of  locked  twins,  in  which  the  body  of  one  twin  was 
born,  its  head  being  locked  with  that  of  the  second,  by  decap- 
itating the  first  twin,  pushing  the  severed  head  up  into  the 
uterus,  delivering  the  second  twin  by  forceps  and  then  the 
severed  head.  Thorough  antisepsis  and  precautions  to  prevent 
haemorrhage  and  secure  good  contraction  of  the  uterus  are  imper- 
ative in  these  cases. 


CHAPTER  XXV. 

THE  PATHOLOGY  OF  PREGNANCY. 

ECLAMPSIA. — By  eclampsia  is  understood  a  convulsive  state  on 
the  part  of  the  mother,  caused  by  the  circulation  in  the  blood  of 
irritating  and  noxious  materials  which  excite  the  nerve  centres. 
These  irritating  substances  result  from  failure  or  deficient  action 
of  the  organs  of  elimination.  In  different  cases,  one  or  other 
organ  seems  most  deficient.  In  some,  the  kidneys  are  greatly  at 
fault,  in  others,  the  liver,  and  in  others,  the  intestines  and  skin. 
It  is  usually  impossible  to  ascribe  to  any  one  organ  the  entire 
causation  of  eclamptic  convulsions,  but  probably  all  of  the 
emunctories  are  in  a  measure  at  fault.  The  clinical  proof  that 
such  is  the  origin  of  eclampsia  is  found  in  the  fact  that  patients 
recover  best  under  methods  of  treatment  which  tend,  while  nar- 
cotizing the  nervous  system,  to  procure  speedy  and  thorough 
elimination. 

Eclampsia  is  most  frequent  in  primagravidae,  especially  those  be- 
yond thirty  years  old.  Predisposing  causes  are  such  as  produce 
progressive  mal-assimilation  with  enfeeblement  of  the  nervous  sys- 
tem. Several  causes  render  the  pregnant  woman  especially  liable 
to  mal-assimilation  and  toxaemia  from  substances  not  thoroughly 
assimilated.  Anatomically,  the  pressure  of  the  enlarged  uterus  may 
occlude  partially  the  ureters,  thus  damming  up  the  urine,  producing 
chronic  congestion  and  impaired  functions  in  the  kidneys.  Since 
attention  has  been  drawn  to  a  toxaemic  condition  as  producing 
eclampsia,  cases  have  been  observed  in  which  icterus,  enlargement 
of  the  liver  and  general  symptoms  of  ptomaine  poisoning  were 
found,  indicating  thaffailure  in  those  functions  of  the  liver  which 
have  to  do  with  the  production  of  the  blood  was  present.  It  must 
be  remembered  that  the  kidneys  are  not  the  only  organs  whose 
166 


THE  PATHOLOGY  OF  PREGNANCY.  167 

failure  to  perform  elimination  properly  produces  eclampsia.  The 
practitioner  must  not  expect  to  find  urine  loaded  with  albumin  and 
casts  in  all  cases  of  eclampsia.  Many  of  the  fatal  cases  have  but 
a  small  percentage  of  albumin  and  few  casts  in  the  urine.  The 
kidneys  of  a  large  proportion  of  pregnant  women  are  engorged 
during  pregnancy,  producing  what  is  called  "the  kidney  of 
pregnancy."  Serum  albumin  and  hyaline  casts  are  not  infre- 
quently found  in  the  urine  during  pregnancy.  In  fact,  cases  in 
which  the  urine  is  loaded  with  casts  and  albumin  not  infrequently 
recover  from  eclampsia,  while  others,  whose  urine  was  almost 
free  from  albumin  and  casts,  die  with  very  little  remission  in  the 
violence  of  their  symptoms.  It  would  seem  that  it  is  not  the 
presence  of  albumin  and  casts,  but  that  of  ptomaines,  which 
proves  dangerous. 

The  diagnosis  of  threatened  toxaemia  is  to  be  made  by  a  careful 
observation  of  the  patient's  condition.  The  physician  should 
know  whether  the  bowels  move  properly ;  the  quantity  and  char- 
acter of  urine  passed ;  the  condition  of  the  skin,  and,  as  far  as 
possible,  whether  the  lungs  are  bearing  their  share  in  elimination. 
Gentle  exercise  in  the  open  air,  with  good  ventilation  in  dwellings, 
is  not  to  be  neglected  in  preventing  toxaemia. 

The  premonitory  symptoms  of  eclampsia  are  those  of  poison- 
ing of  the  nervous  system;  the  cerebrum  acts  deficiently,  the 
patient  is  slightly  stupid,  apathetic  or  irritable;  the  special  senses 
are  disordered :  there  are  flashes  of  light  or  specks  before  the  eyes ; 
there  is  diminished  acutenessof  hearing;  there  is  sometimes  disor- 
dered taste  or  smell.  Frontal  headache  is  often  complained  of, 
and  a  vague  feeling  of  lassitude  and  disquietude  is  often  present. 
The  bodily  functions  are  sometimes  performed  with  a  fair  degree  of 
efficiency,  and,  again,  the  action  of  the  kidneys,  intestines  and 
skin  is  somewhat  below  the  average.  Just  preceding  the  attack 
it  is  not  uncommon  for  the  cerebrum  to  be  considerably  be- 
numbed, so  that  a  patient  may  enter  a  hospital  on  the  verge  of  an 
eclamptic  seizure,  and  afterward  be  unable  to  recall  any  circum- 
stances connected  with  her  admission. 

The  eclamptic   seizure   comprises   tonic   and   clonic   spasms. 


1 63  MANUAL   OF    PRACTICAL   OBSTETRICS. 

The  expression  of  the  patient's  face  becomes  suddenly  staring 
and  unnatural,  the  muscular  system  is  thrown  into  a  tonic  spasm, 
a  deep  breath  is  taken,  followed  by  clonic  spasms,  often  suffi- 
ciently powerful  to  shake  a  patient's  bed  and  exhaust  her  greatly. 
The  jaws  are  clinched,  the  tongue  may  be  bitten  between  the 
teeth,  and,  as  the  stage  of  clonic  spasms  ceases,  froth  and  mucus 
from  the  trachea  and  bronchi  gather  about  the  mouth  and  nos- 
trils. Following  the  clonic  spasms,  a  period  of  coma  supervenes, 
of  greater  or  less  duration.  After  this  the  patient  may  become 
conscious  until  the  advent  of  the  next  eclamptic  fit. 

As  the  spasms  are  repeated,  the  tremendous  muscular  activity 
of  the  clonic  stage  produces  exhaustion  and  rapid  decomposition 
of  the  muscle  substance.  The  products  of  this  decomposition, 
added  to  the  poisonous  materials  already  circulating  in  the  pa- 
tient's blood,  increase  the  violence  and  extent  and  duration  of 
her  spasms.  The  uterus  is  generally  excited  to  activity,  and 
uterine  contractions  bring  on  labor,  which  is  frequently  rapid  and 
violent.  The  fixation  of  the  diaphragm  and  distension  of  the 
lungs,  during  the  stage  of  spasms  and  coma,  favor  pulmonary 
oedema.  From  the  same  causes  cerebral  congestion  supervenes. 
The  nervous  system,  excited  and  depressed  by  the  poisonous 
materials  circulating  in  the  blood,  becomes  gradually  exhausted, 
and  paralysis  of  the  heat  centre  is  followed  by  a  rise  in  tempera- 
ture. Paralysis  of  the  sympathetic  causes  excessive  cardiac  ac- 
tion, with  rapid  pulse  and  subsequent  exhaustion  and  heart-fail- 
ure. Arterial  tension  is  increased  by  the  irritation  of  the  altered 
blood  until  the  stage  of  paralysis  and  exhaustion  is  reached,  and 
the  arterial  wall  loses  much  of  its  contractile  force.  Cerebral 
oedema  and  effusion  into  the  ventricles  of  the  brain  assist  in 
overcoming  the  nervous  system.  Death  results  in  deep  coma, 
with  progressive  failure  of  the  vital  nerve  centres.  Other  causes 
of  death  occurring  during  or  after  eclampsia  are,  exhaustion, 
septic  infection  and  sudden  heart-failure  with  development  of 
heart-clot. 

TREATiMENT. — The  treatment  of  eclampsia  resolves  itself  into 
prophylaxis,  and  the  treatment  of  the  patient  during  the  convul- 


THE  PATHOLOGY  OF  PREGNANCY.  169 

sions.  From  what  has  bean  said,  it  can  readily  be  understood 
that  the  prophylactic  treatment  must  be  addressed  to  furthering 
and  maintaining  a  proper  elimination.  It  should  be  the  invariable 
custom  of  the  physician  to  examine  the  urine  of  patients  at  inter- 
vals of  two  or  three  weeks  during  pregnancy.  Especial  attention 
should  also  be  given  to  the  regular  and  proper  action  of  the  intes- 
tines and  skin,  and  nutritious  and  easily  assimilated  diet  should 
be  advised,  with  the  avoidance  of  unusual  and  prolonged  exercise 
and  exposure  to  damp  and  cold.  The  practitioner  should  remember 
that  the  presence  or  absence  of  albumin  in  the  urine  is  not  of 
great  significance  as  regards  the  occurrence  of  eclampsia.  The 
most  valuable  method  of  studying  the  condition  of  the  kidneys  is 
by  a  microscopic  examination  of  the  urinary  sediment.  Should 
granular  or  fatty  casts  be  found  and  should  they  persist,  and  albu- 
min also  be  present,  there  can  be  no  doubt  but  that  the  kidneys 
are  at  fault. 

The  diet  best  adapted  for  patients  threatened  with  eclampsia  is 
milk.  It  is  often  difficult,  however,  to  restrict  patients  to  this 
only,  as  many  soon  acquire  an  intense  disgust  for  this  article  of 
diet.  Highly  nitrogenous  foods  should  be  avoided,  and  also  an 
excess  of  sugar  and  fat  and  any  substance  liable  to  derange  the 
action  of  the  liver  and  intestines.  If  the  patient  cannot  be 
restricted  to  milk,  soft-boiled  eggs,  fish,  white  meat  of  fowls, 
fruits,  vegetables,  stale  bread  and  the  use  of  an  abundance  of  soft 
drinking  water  should  be  advised. 

To  secure  proper  action  of  the  intestines,  it  will  often  be  neces- 
sary to  prescribe  laxatives.  Salts  should  be  avoided,  as  it  has 
been  ascertained  that  potassium  salts  especially  act  as  irritants  in 
the  blood  in  these  conditions  and  hence  favor  convulsions.  Colo- 
cynth,  senna,  compound  licorice  powder,  with  the  occasional 
use  of  small  doses  of  calomel,  are  indicated.  Glycerine  and 
gluten  suppositories  and  occasional  enemata  may  "be  employed  to 
assist  in  keeping  the  bowels  regular.  The  action  of  the  skin 
should  be  maintained  by  frequent  bathing  in  tepid  or  warm  water. 
The  fabric  worn  next  to  the  skin  should  be  woolen  to  promote  a 
constant  and  free  circulation  of  blood  in  the  skin,  thus  tending 
8 


170  MANUAL    OF    PRACTICAL    OBSTETRICS. 

to  relieve  the  viscera  from  congestion.  Alcoholic  liquors  should 
be  avoided  as  beverages,  and  also  the  use  of  tea  and  coffee  in  excess, 
and  any  narcotic  substance.  The  patient  will  avoid  prolonged 
and  fatiguing  exertion,  such  as  difficult  journeys,  and,  if  possible, 
should  pass  her  pregnancy  in  a  dry  and  equable  climate. 

In  proportion  as  the  severity  of  the  symptoms  increases,  the 
practitioner  may  employ  more  active  measures  to  secure  elimina- 
tion. The  best  of  these  consists  in  arousing  the  activity  of  the 
skin  vigorously  by  the  use  of  a  hot  bath.  The  patient  should  be 
in  a  tub  of  water  at  a  temperature  of  80  or  90,  and  the  tempera- 
ture be  then  raised  until  the  limit  of  endurance  is  nearly  reached. 
While  in  the  bath  she  should  drink  freely  of  hot  water,  and  after 
leaving  the  bath  she  should  lie  wrapped  in  blankets  for  a  couple 
of  hours. 

There  is  no  one  drug  of  value  as  a  preventer  of  eclampsia,  and 
the  temptation  to  prescribe  sedatives  and  narcotics  should  be 
strenuously  opposed,  while  the  cause  and  pathology  of  the  con- 
dition will  give  the  practitioner  an  accurate  guide  for  treatment 
in  the  indication  to  further  and  maintain  elimination. 

The  treatment  of  eclamptic  convulsions  consists  first  in  so 
narcotizing  the  patient  as  to  modify  the  violence  of  the  convul- 
sions, thus  preserving  the  nervous  system  from  rapid  destruction, 
and  in  securing  prompt  and  thorough  elimination.  Two  narcotics 
are  of  especial  value,  chloroform  and  chloral.  Morphia  is  also 
often  employed,  and  has  been  used  with  the  best  possible  results. 
The  administration  of  chloroform  is  of  primary  importance,  as  no 
other  narcotic  so  promptly  controls  the  convulsions.  If  possible, 
the  task  of  giving  chloroform  should  be  intrusted  to  one  person 
only,  who  should  sit  beside  the  patient,  ready  to  administer  the 
anaesthetic  at  the  slightest  indication  of  the  convulsion.  To  pre- 
vent the  patient  from  biting  her  tongue,  a  folded  handkerchief  or 
napkin  should  be  placed  between  the  jaws.  A  clean  handkerchief 
or  napkin  may  be  used  as  an  inhaler,  and  sufficient  chloroform  be 
poured  upon  it  to  secure  a  speedy  and  positive  effect.  Chloral 
may  be  given  by  rectal  injection  in  doses  of  30  or  40  grains, 
repeated  at  intervals  of  two  or  three  hours,  until  from  60  to  90 


THE  PATHOLOGY  OF  PREGNANCY.  171 

grains  have  been  taken.  Morphia  may  be  administered  hypoder- 
mically  in  doses  of  one-fourth  or  one-half  a  grain,  and  in  com- 
bination with  atropia  when  a  tendency  to  respiratory  failure  is 
present. 

The  subduing  the  violence  of  the  paroxysms,  however,  will  be 
useless  to  save  the  life  of  the  patient  unless  prompt  elimination  is 
secured.  This  is  best  done  by  the  employment  of  the  hot  bath 
in  the  following  way :  the  patient  is  raised  upon  the  sheet  on 
which  she  lies,  and  both  are  placed  in  a  tub  of  water  at  a  tem- 
perature of  90.  Sufficient  ground  mustard  to  redden  the  patient's 
skin  should  be  thrown  into  the  water,  and  the  temperature  of  the 
bath  should  be  raised  rapidly  until  the  tolerance  of  those  whose 
hands  are  in  the  bath  has  been  reached.  If  symptoms  of  heart- 
failure  present  themselves,  digitalis  may  be  given  hypodermically 
while  the  patient  is  in  the  bath.  Ordinarily,  fifteen  or  twenty 
minutes  will  suffice  to  keep  the  patient  in  the  bath.  The  patient's 
skin  should  also  be  rubbed,  and  when  the  skin  is  thoroughly 
reddened  she  should  be  taken  from  the  bath  upon  the  sheet,  a 
blanket  wrapped  hastily  about  her,  and  laid  upon  a  bed  covered 
with  a  rubber  blanket.  Woolen  blankets  should  then  be  added 
in  abundance,  with  hot  cans  at  the  feet  and  about  the  thighs  ; 
after  a  few  moments  the  patient's  forehead  will  be  seen  to  be 
moistened  by  perspiration,  which  will  usually  become  profuse  in 
a  short  time.  Meanwhile,  a  rectal  injection  of  chloral  may  be 
given,  and  morphia  used  hypodermically  if  needed. 

To  secure  elimination  in  desperate  cases,  a  drop  of  croton-oil 
mixed  with  olive-oil  may  be  placed  upon  the  tongue.  It  will 
usually  be  better,  however,  if  the  patient  can  swallow,  to  employ 
calomel  as  a  diuretic  and  also  as  a  purgative.  For  this  purpose, 
ten  grains  of  calomel  with  an  equal  quantity  of  soda  should  be 
swallowed  as  soon  as  possible.  This  dose  should  not  be  repeated 
but  once  in  thirty-six  hours.  It  may  be  followed  an  hour  after- 
ward by  a  laxative  injection.  The  practitioner,  meanwhile, 
should  observe  carefully  the  patient's  pulse  and  temperature.  If 
she  be  threatened  with  heart -failure,  digitalis  and  ammonia  may 
be  given  by  hypodermic  injection.  If  the  pulse  continues  to 


172  MANUAL   OF    PRACTICAL    OBSTETRICS. 

rise,  remaining  above  100,  the  prognosis  becomes  correspond- 
ingly grave  as  the  case  proceeds.  It  is  not  unusual  to  observe  a 
temperature  of  103  or  104°  F.  in  these  cases,  usually  falling  under 
the  influence  of  the  hot  bath.  If  stimulants  are  required,  whis- 
key and  milk,  two  ounces  of  each,  may  be  warmed  and  given 
by  rectal  injection.  In  apoplectiform  cases  where  plethora  is 
excessive,  bleeding  may  be  practiced  with  marked  temporary 
benefit.  No  permanent  improvement  can  be  expected,  as  this 
expedient  will  not  exercise  more  than  a  temporary  influence  upon 
the  patient. 

The  effect  of  eclamptic  convulsions  is  usually  to  bring  on 
labor.  If  the  convulsions  be  violent  the  uterine  muscle  often 
shares  in  the  general  muscular  activity.  Labor  is  sometimes 
rapid  and  precipitate.  When  the  practitioner  finds  that  labor 
has  commenced,  he  will  do  well  to  further  its  completion.  Thus, 
when  dilatation  is  sufficient,  the  forceps  may  often  be  used  to 
advantage,  or  version  may  terminate  the  labor.  If,  however, 
dilatation  is  not  complete,  and  no  signs  of  labor  are  present,  no 
effort  should  be  made  to  forcibly  dilate  the  cervix  and  empty  the 
uterus.  Such  a  procedure  would  simply  add  to  the  reflex  excita- 
bility of  the  general  nervous  system,  and  further  a  fatal  result 
for  the  mother  and  child.  After  labor  the  convulsions  may  con- 
tinue, although  this  is  exceptional  and  not  the  rule. 

The  prognosis  of  eclampsia  has  improved  since  our  knowledge 
of  the  pathology  of  the  affection  has  become  more  accurate. 
While  formerly  more  than  one-third  of  all  eclamptic  patients 
died  (33^  per  cent.),  under  treatment  planned  upon  indications 
furnished  by  the  pathology  of  the  affection,  but  one-thirteenth 
(7^  per  cent.)  died.  Eclampsia  occurring  during  the  first  stage 
of  labor  is  more  fatal  than  that  which  comes  on  before  labor  has 
begun.  The  death  of  the  child  before  labor  begins  improves  the 
mother's  chances,  probably  by  removing  a  source  of  uterine 
irritation  in  foetal  movements  and  the  waste  products  of  foetal 
digestion. 

In  eclamptic  patients  an  occasional  error  may  arise  through 
the  existence  of  hysteria  complicating  nephritis.  Thus,  in  a 


THE  PATHOLOGY  OF  PREGNANCY. 


173 


recent  case  in  which  nephritis  was  well  'marked,  the  patient  was 
observed  to  have  paroxysms  simulating  eclamptic  seizures.  A 
few  moments'  careful  observation  detected  the  evident  counter- 
feit. It  is  interesting  to  observe  that  although  this  patient  had 
well-marked  nephritis,  she  never  had  a  genuine  eclamptic 
seizure. 

Epilepsy  may  simulate  eclampsia  very  closely.  The  examina- 
tion of  the  urine  and  the  results  of  treatment  will  usually  enable 
the  obstetrician  to  make  a  differential  diagnosis. 

The  prognosis  for  the  child  in  eclamptic  cases  is  rendered 
unfavorable  through  the  usual  rapidity  and  precipitateness  of  the 
labor.  In  spite  of  all  this,  however,  children  are  frequently  born 
and  live  after  labor  occurring  during  eclamptic  convulsions.  A 
mother  who  has  had  eclampsia  should  not  nurse  her  child. 

NEPHRITIS  OCCURRING  DURING  PREGNANCY. — While  toxaemia 
and  eclampsia  are .  well  recognized  conditions,  it  has  been 
customary  to  ascribe  all  eclampsia  to  kidney  failure.  This  is  but 
partially  true,  and  nephritis  during  pregnancy  is  to  be  recognized 
as  an  affection  distinct  from  toxaemia  and  eclampsia,  although 
predisposing  to  them.  The  causes  producing  nephritis  in  the 
non-pregnant  operate  more  readily  during  pregnancy,  from 
the  burdened  condition  of  the  mother's  emunctories  owing 
to  the  demands  of  the  foetal  economy ;  exposure  to  wet  and  cold, 
poor  and  improper  food  and  the  causes  which  produce  an  altered 
and  irritating  blood,  resulting  in  arterial  disease  and  ultimately 
kidney  failure,  commonly  cause  nephritis.  The  symptoms  are 
those  usually  observed,  casts  and  albumin  in  the  urine,  with 
cedema,  lessened  amount  of  urine  and  uraemia. 

A  point  of  especial  interest  to  the  obstetrician  is  the  relation 
which  nephritis  caused  by  disease  of  the  arterioles  of  the  kidney 
bears  to  the  life  of  the  fcetus.  While  the  pathology  of  the  condition 
is  not  perfectly  demonstrated,  yet  observation  seems  to  show  that 
while  the  arterioles  of  the  mother's  kidneys  are  becoming  gradually 
occluded  by  diseased  products,  a  similar  change  is  going  on  in 
the  small  vessels  of  the  placenta.  This  process  gradually  occludes 
areas  in  the  placenta,  thus  robbing  the  foetus  of  portions  of  its 


174  MANUAL   OF   PRACTICAL   OBSTETRICS. 

blood  supply  and  gradually  causing  death  by  asphyxia.  In  the 
interests  of  mother  and  child,  a  time  must  come  when  the  induc- 
tion of  labor  is  justified  in  the  interests  of  both.  Women  having 
well  marked  nephritis  are  not  apt  to  recover  perfectly  after  labor 
and  are  more  liable  to  eclampsia ;  the  foetus  of  such  a  mother 
often  dies  in  the  uterus  before  labor  comes  on,  or  perishes  soon 
after  birth.  It  is  difficult  to  determine  the  exact  time  at  which  to 
induce  labor,  and  this  can  be  known  only  from  an  accurate  and 
prolonged  observation  of  the  case.  But  it  is  certainly  true,  in  the 
present  stage  of  our  knowledge,  that  pregnancy  should  be  inter- 
rupted in  a  patient  having  well-marked  symptoms  of  nephritis 
which  do  not  abate  on  treatment. 

The  treatment  of  nephritis  during  pregnancy  does  not  differ 
from  that  in  the  non-pregnant.  The  warm  and  hot  bath ; 
proper  hygiene ;  laxatives  which  produce  free,  watery  stools ; 
the  use  of  pure,  soft  drinking  water  are  the  ground  work  of 
treatment.  It  should  be  remembered  that  it  is  not  the  amount 
of  serum  albumin  in  the  urine  which  indicates  danger,  but  casts 
and  kidney  debris,  and  hence  careful  microscopic  examination  of 
the  urine  is  more  valuable  than  chemical  tests. 


CHAPTER    XXVI. 

INFECTIOUS  AND  CARDIAC  DISEASE  DURING  PREGNANCY. 

THE  ACUTE  INFECTIONS  OCCURRING  DURING  PREGNANCY. — 
Great  interest  has  attached  to  the  acute  infections  since 
bacteriology  has  thrown  new  light  upon  the  causation  of  such 
maladies.  The  question  naturally  suggests  itself,  can  the  germs 
causing  the  acute  infections  pass  through  the  villi  of  the  chorion 
and  the  inter-villous  placental  septa  and  infect  the  foetus  as  well  ? 
At  the  present  time  an  affirmative  answer  can  be  given  to  this 
question  as  regards  typhoid  infection,  malaria,  pneumonia, 
syphilis,  tuberculosis  and  gonorrhoea.  It  is  also  stated  that 
cholera  and  yellow  fever  are  transmitted  from  mother  to  child, 
the  latter  in  such  a  manner  as  to  convey  immunity  from  subse- 
quent attacks  upon  the  foetus  which  survives,  while  in  the  uterus, 
an  attack  of  the  disease. 

The  exanthematous  infections  are  conveyed  to  the  foetus, 
variola,  measles,  scarlatina,  and  erysipelas  frequently  causing 
foetal  death,  before  or  after  delivery. 

It  seems  to  have  been  demonstrated  that  pregnancy  neither 
exempts  or  exposes  a  woman  to  the  acute  infections.  She  incurs 
greater  dangers  than  the  non-pregnant  from  abortion,  from 
haemorrhage  and  from  the  fact  that  in  some  of  the  infections 
mentioned,  as  variola,  scarlatina  and  erysipelas,  the  micrococci 
which  cause  puerperal  pyaemia  frequently  develop  in  company 
with  the  germs  of  the  original  infection,  and  hence  puerperal 
sepsis  is  added  as  a  complication. 

The  symptoms  of  these  diseases  in  pregnancy  do  not  essentially 
differ  from  those  in  the  non-pregnant.  The  symptoms  of 
abortion  are  likely  to  be  added  to  those  of  the  original  infection, 
and  should  not  fail  to  attract  the  physician's  attention.  As 

175 


176  MANUAL   OF    PRACTICAL    OBSTETRICS. 

regards  prognosis,  if  the  patient's  temperature  does  not  remain 
long  at  or  above  104°  F.  her  chances  and  those  of  the  foetus  are 
not  desperate  so  far  as  fever  is  concerned.  The  occurrence  of 
abortion  is  unfavorable ;  a  premature  labor  is  not  especially 
dangerous.  The  prognosis  of  abortion  or  premature  labor  occur- 
ring during  an  acute  infection  will  be  greatly  influenced  by  the 
observance  or  disregard  of  antiseptic  precautions.  As  there  is, 
in  these  cases,  especial  danger  of  the  development  of  micrococci, 
so  there  is  indicated  especial  precaution.  If  haemorrhage  be 
prevented,  the  patient's  strength  be  conserved,  and  sepsis  does 
not  complicate  the  case,  a  better  prognosis  can  be  given  than 
would  otherwise  be  justifiable. 

The  treatment  of  the  acute  infections  during  pregnancy  is 
that  proper  in  the  non-pregnant,  with  especial  attention  to  the 
reduction  of  temperature.  No  theory  or  method  of  treatment 
appropriate  in  such  cases  is  contra  indicated  because  of  preg- 
nancy, but  whatever  will  best  further  the  mother's  interests  will 
be  best  for  the  child.  Quinine  may  be  given  freely  during 
malarial  infection  without  fear  of  producing  abortion.  When 
abortion  or  labor  has  begun,  quinine,  in  common  with  many 
tonics  acting  upon  the  nervous  system,  is  most  efficient  in 
strengthening  the  contraction  of  the  uterus.  It  will  rarely  cause 
abortion  or  labor  before  such  a  process  has  actually  commenced. 
Stimulants  may  be  used  as  freely  as  needed  with  the  best  results. 
Abortion  should  not  be  intentionally  produced,  as  it  increases  the 
mother's  dangers. 

In  variola  and  syphilis,  preventive  medication  may  be  em- 
ployed advantageously  for  the  interest  of  the  foetus.  Vaccina- 
tion should  be  performed  so  soon  as  variola  is  suspected,  and 
pregnancy  is  no  counter  indication  to  vaccination  in  all  cases. 
The  prompt  use  of  mercury  'in  recent  syphilitic  infection  is 
demanded  in  the  interests  of  the  foetus.  Preventive  inocula- 
tions with  tuberculin  do  not  as  yet  give  promise  of  success  in 
threatened  foetal  tuberculosis.  Gonorrhoeal  infection  during 
pregnancy  demands  prompt  treatment.  The  vagina  should  be 
thoroughly  douched  with  a  solution  of  bi-chloride  of  mercury, 


INFECTIOUS  AND  CARDIAC  DISEASE  DURING  PREGNANCY.      177 

one  to  one  thousand,  followed  by  boiled  water.  lodoform  is 
then  to  be  thoroughly  applied  to  the  mucous  membrane,  a  tam- 
pon of  iodoform  gauze,  which  distends  the  vagina  moderately,  is 
especially  useful.  Injections  may  be  given  to  advantage  through 
a  cylindrical  speculum.  The  early  destruction  of  the  gonococci 
is  desirable,  as  they  tend  to  nest  in  the  folds  of  the  vaginal  mu- 
cous membrane,  and  thus  infect  the  mucous  surfaces  of  the  foetus 
during  labor.  They  also  threaten  the  mother  with  infection  of 
the  urinary  tract.  Continued  gonorrhoeal  inflammation  during 
pregnancy  causes  in  many  cases  adherence  of  the  foetal  mem- 
branes to  the  cervix  and  os ;  at  labor  premature  rupture  of  the 
membranes  results,  and  a  tedious  and  difficult  labor  may  follow. 
CARDIAC  DISORDERS  DURING  PREGNANCY. — The  physiological 
changes  occurring  in  normal  pregnancy  tend  to  exaggerate  a  dis- 
eased condition  of  the  heart  before  pregnancy.  The  tax  put 
upon  the  mother's  circulatory  system  by  the  needs  for  foetal  nu- 
trition favors,  in  advanced  cardiac  lesions,  failure  in  nutrition  in 
the  hypertrophied  heart  muscle  and  dilatation  occurs,  increasing 
to  a  dangerous  degree  during  labor.  If  the  valvular  lesion  be 
slight,  compensation  may  be  maintained,  and  no  immediate 
harm  follow  pregnancy  and  labor.  Repeated  pregnancies  and 
labor  should  be  avoided;  in  fact,  women  with  well-marked  car- 
diac lesions  should  not  become  pregnant.  During  pregnancy 
violent  exertion  must  be  avoided,  and  chilling  the  surface  of 
the  body.  The  clothing  should  be  perfectly  loose ;  the  skin, 
bowels,  kidneys  and  lungs  should  be  kept  in  proper  activity. 
The  nutrition  of  the  heart  muscle  is  to  be  maintained  by  attention 
to  nutrition,  with  the  use  of  cardiac  tonics.  The  sensation  of 
breathlessness,  which  so  often  annoys  pregnant  women,  should 
be  explained  to  the  patient,  and  should  not  be  allowed  to 
cause  undue  apprehension.  The*  physician  will  inform  himself 
by  physical  examination  of  the  actual  condition  present.  At 
labor  the  patient's  dyspnoea  is  best  relieved  by  the  hypodermic 
use  of  ether,  atropia,  strophanthus  or  digitalis  and  strychnia, 
with  inhalations  of  chloroform  or  ether.  If  possible,  oxygen 
should  be  in  readiness  for  inhalation.  Labor  may  be  judiciously 


178  MANUAL   OF    PRACTICAL   OBSTETRICS. 

expedited  by  forceps  or  version.  Haemorrhage  is  to  be  feared, 
and  possible  thrombosis  after  delivery.  The  relief  afforded  by 
anaesthetics  in  cases  of  labor  with  advanced  valvular  lesions  is 
surprising  and  immediate.  In  common  with  other  disorders, 
cardiac  lesions  are  not  incurred  by  pregnancy,  but  are  aggravated 
by  it.  Endocarditis,  caused  by  rheumatism,  is  most  frequent, 
atheroma  and  aneurism  are  less  commonly  observed  than  in 
men. 

The  occurrence  of  failure  of  nutrition  in  the  heart  muscle, 
with  beginning  dilatation,  may  justify  the  production  of  abor- 
tion. 


CHAPTER    XXVII. 

AFFECTIONS  OF  THE   GENITO-URINARY  ORGANS  OCCURRING  DURING 

PREGNANCY. 

THE  condition  of  pregnancy  predisposes  to  inflammation  of  the 
mucous  membrane  of  the  vagina  and  cervix.  Simple  engorge- 
ment, with  increased  secretion  of  mucus,  is  almost  a  constant 
condition  of  the  vaginal  mucous  membrane.  Unless  precautions 
are  taken  to  insure  cleanliness,  micrococci  will  breed  in  the  de- 
composed secretions,  and  inflammation  and  ulceration  will  result. 
The  symptoms  of  such  conditions  are  vaginal  discharges,  and 
pain  and  irritation  upon  micturition  and  walking.  Treatment 
should  be  addressed  first  to  destroying  micrococci  and  next  to 
maintaining  a  condition  of  cleanliness  by  vaginal  injections. 
Bichloride  of  mercury,  i  to  5000  or  2000,  will  be  useful  at  first, 
to  be  followed  later  by  injections  of  boric  acid  or  alum  in  dilute 
solutions.  The  treatment  of  gonorrhoea  has  been  considered  under 
the  acute  infections. 

When  micrococci  invade  the  bladder,  a  trying  complication  of 
pregnancy,  and  one  likely  to  occasion  trouble  after  labor,  is 
present.  Urethritis,  cystitis,  pyelitis  and  suppurating  kidney  have 
all  followed  this  accident.  When  pus  is  found  in  the  urine  the 
bladder  should  be  douched  twice  daily  with  creoline  solution,  a 
teaspoonful  to  the  pint  of  warm  water.  Internally  salol  may  be 
given,  10  grains  three  times  daily,  or  boracic  acid  15  to  20  grains 
three  times  daily.  Milk  diet,  if  possible,  with  rest  in  bed  and 
careful  disinfection  of  the  vagina,  will  also  be  of  advantage.  It 
is  of  interest  to  note  that  cystitis  of  moderate  degree  may  be 
present  with  an  acid  urine  in  the  case  of  women.  In  pyelitis, 
catheterization  of  the  ureters  is  of  value  to  determine  which 

179 


180  MANUAL   OF    PRACTICAL   OBSTETRICS. 

kidney  is  affected  :  in  severe  and  prolonged  cases  lumbar  incision 
and  drainage  of  the  kidney  are  indicated. 

Displacement  of  the  uterus  and  vagina  are  among  the  complica- 
tions of  pregnancy.  Prolapse  of  the  vaginal  walls  is  usually  the 
result  of  repeated  parturitions,  with  a  relaxed  condition  of  the 
tissues. 

Prolapse  of  the  uterus  may  occur  early  in  pregnancy,  accom- 
panied by  endocervicitis ;  although  previous  distension  of  the 
vagina  during  labor  is  an  exciting  cause,  it  may  be  observed  in 
primagravida.  Its  symptoms  are  sensations  of  weight  and  drag- 
ging, the  presence  of  a  tumor,  with  interference  with  the  functions 
of  the  bladder  and  rectum.  Abortion  may  result  if  the  case  be 
neglected,  with  septic  infection  following  it. 

Replacement  of  the  prolapsed  organ  and  its  retention  in  its 
normal  position  can  usually  be  effected  by  manipulation.  An 
antiseptic  tampon  is  a  convenient  and  efficient  agent  for  retaining 
the  uterus  in  its  normal  position.  Surgeons'  lint,  in  strips  three 
inches  wide,  smeared  with  an  antiseptic  ointment,  is  a  useful 
material  for  tampon.  Hard  and  elastic  pessaries  are  not  contra- 
indicated  in  these  cases.  In  extensive  prolapse  of  the  vaginal 
walls,  with  laceration  and  erosion  of  the  cervix,  colporrhaphy  and 
trachelorrhaphy  may  be  performed  without  fear  of  abortion,  if 
undue  violence  be  avoided  and  antiseptic  precautions  be  taken  to 
secure  union  by  first  intention. 

RETRO-DISPLACEMENT  OF  THE  PREGNANT  UTERUS — It  is  not 
uncommon  for  the  uterus  to  tip  backward  early  in  pregnancy. 
The  frequency  of  backward  displacements  in  the  non-pregnant, 
tight  clothing  and  corsets  worn  during  pregnancy,  and  relaxation 
of  the  supports  of  the  uterus  as  its  weight  increases,  have  all  been 
alleged  as  causes  of  this  condition.  Between  the  third  and  fourth 
month,  when  the  uterus  rises  out  of  the  pelvis,  such  a  displacement 
is  usually  spontaneously  corrected  ;  if  inflammation  and  adhesions 
exist,  binding  the  uterus  down,  abortion  or  death  of  the  foetus 
and  impaction  of  the  uterus  in  the  hollow  of  the  sacrum  will 
result. 

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frequent  and  irritating  micturition,  constipation,  and  pain  over 
the  sacral  and  gluteal  regions.  Digital  examination  will  confirm 
the  physician's  suspicions. 

The  treatment  of  this  complication  of  pregnancy,  in  mild  cases, 
consists  in  emptying  the  bladder  and  rectum,  anteverting  the 
uterus  by  pressure  with  the  fingers  in  the  vagina  or  rectum,  and 
fitting  a  pessary,  either  of  hard  rubber  or  some  softer  material,  to 
retain  the  uterus  in  position.  In  replacing  the  uterus,  violent 
manipulation  must  be  avoided  ;  if  the  patient  be  placed  in  the 
knee-chest  posture  the  uterus  will  generally  go  easily  into  place. 
A  support  will  not  be  needed  after  the  fourth  month,  when  the 
uterus  has  risen  above  the  pelvic  brim. 

In  impaction  of  the  pregnant  uterus  in  the  hollow  of  the 
sacrum,  persistent  but  gentle  efforts  are  needed  to  dislodge  it 
from  its  abnormal  position.  The  cervix  may  be  grasped  by  a 
tenaculum  forceps  and  drawn  downward  and  backward,  while 
with  the  fingers  of  the  other  hand  an  effort  is  made  to  dislodge 
the  fundus.  If  the  uterus  cannot  be  replaced,  its  size  must  be 
lessened  by  producing  abortion ;  this  is  best  accomplished  by 
introducing  a  sound,  rupturing  the  membranes.  When  the 
uterus  is  bound  down  by  adhesions,  impacted  in  the  hollow  of 
the  sacrum,  and  death  and  decomposition  of  the  foetus  ensue, 
the  condition  is  one  of  gravity.  The  obstetrician  is  then  obliged 
to  forcibly  break  up  such  adhesions,  replace  the  uterus  and 
empty  and  disinfect  its  cavity.  The  uterus  has  been  extirpated 
through  the  vagina  for  the  relief  of  this  condition,  with  success. 

ANTERIOR  DISPLACEMENT  OF  THE  PREGNANT  UTERUS. — In 
women  whose  abdominal  walls  are  ill  developed,  weakened  by 
many  pregnancies,  and  in  pregnant  women  having  contracted 
pelves  so  small  that  the  uterus  cannot  enter  the  pelvic  cavity, 
exaggerated  ante-version  of  the  pregnant  uterus  has  been  observed. 
Its  symptoms  are  interference  with  the  function  of  the  bladder, 
first  frequent  micturition,  then  infrequent  difficult  micturition, 
and  finally  the  retention  of  the  contents  of  the  bladder  with 
almost  constant  dribbling  of  urine.  The  abdomen  protrudes  as 
the  uterus  grows  larger,  until  the  German  term  of  "hanging 


1 82  MANUAL   OF    PRACTICAL   OBSTETRICS. 

belly"  seems  appropriate.  Pain  and  "dragging"  are  felt  in 
the  sacral  region. 

The  diagnosis  of  the  condition  is  readily  made  by  examination 
after  the  bladder  has  been  emptied  by  a  catheter.  In  early 
pregnancy  a  ring  pessary  will  usually  correct  the  malposition  ; 
later  in  pregnancy  a  broad  abdominal  band  will  be  found  use- 
ful. 

RELAXATION  OF  THE  PELVIC  JOINTS  is  an  occasional  complication 
of  pregnancy.  Although  these  joints  become  more  vascular,  and 
contain  more  synovial  fluid  than  in  the  non  pregnant,  it  is  rare 
for  their  mobility  to  become  excessive.  The  pubic  joint  is 
most  affected  in  these  cases,  and  can  be  felt  to  move  freely  when 
the  patient  steps.  Walking  may  become  impossible,  and  stand- 
ing be  scarcely  endured.  There  is  no  one  cause  which  seems 
responsible  for  this  condition,  and  hence  no  treatment  except 
mechanical  devices  for  partly  immobilizing  the  joint  is  of  avail. 
The  application  of  a  broad,  well  fitting  bandage  of  strong 
material,  passing  around  the  entire  pelvis  from  the  trochanters 
above  the  crests  of  the  ilia,  is  usually  efficient.  A  plaster-of- Paris 
bandage  has  been  necessary  in  severe  cases,  and  in  others  rest  in 
bed. 

THE  NERVOUS  SYSTEM. — Pregnancy  affects  the  nervous  sys- 
tem, often  profoundly.  The  reflexes  are  exaggerated;  the  tro- 
phic and  secretory  nerves  are  more  active,  and  more  easily 
excited.  The  brain  shares  in  the  generally  sensitive  condition 
of  the  patient,  and  the  pregnant  woman  is  often  easily  frightened, 
irritable  and  usually  apprehensive.  A  generally  stimulating 
effect  is  observed  with  others,  and  such  women  feel  better  than 
when  not  pregnant.  Such  patients  have  better  appetite  and 
digestion  than  before  pregnancy.  The  sensitive  condition  of 
the  sympathetic  nervous  system  causes  cardiac  palpitation,  dys- 
pnoea, flushing  of  the  features  and  often  perspiration  on  very 
slight  provocation.  Salivation,  discoloration  of  the  skin  about  the 
face  and  often  the  genital  organs,  and,  in  many  cases,  excessive 
nausea  and  vomiting,  are  all  to  be  referred  to  hyperaesthesia 
of  the  various  portions  of  the  nervous  system,  caused  by  pregnancy. 


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DISORDERS    OF    THE    NERVOUS    SYSTEM.  183 

The  extremes  of  these  nervous  affections  are  seen  in  chorea 
and  insanity,  recurring  during  pregnancy.  It  is  rare  that  either 
is  caused  by  pregnancy,  but  results  in  a  pregnant  woman  predis- 
posed to  either  of  them.  The  treatment  of  chorea  in  the  pregnant 
woman  is  essentially  that  in  the  non -pregnant.  Abortion  should 
be  resofted  to  only  when  other  remedies  have  failed,  and  prema- 
ture labor  in  the  choreic  rarely  terminates  spontaneously.  Arsenic 
and  other  tonics  to  the  nervous  system  act  very  favorably  in  these 
cases,  especially  when  accompanied  by  disciplined  nursing. 

In  a  woman  predisposed  by  heredity  to  insanity,  pregnancy 
not  infrequently  developes  melancholia,  with  acute  mania  at 
labor.  In  those  not  predisposed  to  insanity,  pregnancy  may  be 
accompanied  by  melancholia  persisting  for  some  time  after  deliv- 
ery, but  rarely  followed  by  mania. 

Labor  in  the  actively  insane  demands  careful  attention.  Such 
patients  are  often  strangely  oblivious  to  pain,  and  labor  may 
proceed  without  demonstrations  of  suffering.  Anaesthetics  and 
sedatives  are  required  in  these  cases  and  delivery  should  be  con- 
ducted under  complete  anaesthesia.  Constant  watchfulness  is  to 
be  exercised,  for  suicidal  tendencies  and  efforts  to  injure  the  child 
are  not  infrequent.  Judicious,  kindly  restraint  is  imperative  in 
these  cases,  and  the  physician  may  find  his  strength  and  patience 
taxed  to  their  utmost.  It  is  sometimes  necessary  to  partially  an- 
aesthetize the  patient  to  give  even  a  douche.  The  prognosis  in 
those  not  predisposed  to  insanity  is  good,  under  long-continued 
and  rational  treatment.  Seclusion,  tonics,  cheerful  and  assidu- 
ous kindness,  and  the  presence  of  the  child  usually  cure  these 
cases.  In  those  with  whom  insanity  was  to  be  feared,  pregnancy 
is  simply  the  exciting,  but  not  the  predisposing  cause,  any  one 
of  many  might  have  precipitated  mental  disease.  The  prognosis 
for  recovery  in  such  cases  cannot  be  given  as  hopeful. 

Hysteria  and  epilepsy  are  neither  caused  nor  greatly  aggra- 
vated by  pregnancy.  Both  are  to  be  treated  as  in  the  non-preg- 
nant. Hysteria  may  deceive  the  practitioner  by  simulating  labor 
and  even  eclampsia ;  close  observation  will  detect  the  decep- 
tion. The  diagnosis  between  eclampsia  and  epilepsy  will  be 


184  MANUAL   OF    PRACTICAL   OBSTETRICS. 

made  by  the  history,  when  available,  and  by  the  examination  of 
the  urine;  the  epileptic  has  had  fits  before  pregnancy,  her  par- 
oxysms do  not  grow  more  frequent  or  violent ;  she  rarely  dies 
during  or  after  labor. 

PERNICIOUS  VOMITING  OF  PREGNANCY. — In  some  cases,  with- 
out anatomical  lesion  to  account  for  the  disorder,  the  nausea  and 
vomiting  of  pregnancy  become  so  exaggerated  as  to  threaten  the 
patient's  life.  When  the  examination  of  the  patient  fails  to  de- 
tect irritation  or  inflammation  about  the  uterus;  when  the  womb 
is  in  normal  position,  and  no  gastric  or  kidney  disease  can  be 
detected,  the  cause  of  the  nausea  must  be  ascribed  to  a  hyper- 
sensitive condition  of  the  nervous  system.  Disease  of  the  foetal 
appendages  has  been  found  in  some  cases  of  pernicious  vomiting, 
but  the  relationship  of  cause  and  effect  has  not  been  demon- 
strated. Some  observers  have  made  hysteria  the  cause  of  nausea 
and  vomiting,  although  proof  that  such  is  invariably  the  case  is 
not  forthcoming. 

In  these  cases  remedies  are  most  successful  which  act  as  seda- 
tives to  the  nervous  system.  The  bromides,  chloral,  morphia, 
antipyrin,  antifebrin  or  phenacetin,  cocaine  or  valerian  are  in- 
dicated. Chloroform,  internally  and  by  inhalation,  is  some- 
times successful.  Locally,  counter-irritation  over  the  epigas- 
trium; heat  to  the  cerebrum  and  cerebellum;  galvanism  along 
the  spine  and  epigastrium,  or  an  ice-bag  upon  the  abdomen  are 
measures  which  have  been  of  value  in  different  cases.  When 
other  treatment  is  unavailing,  and  the  patient  is  threatened  with 
collapse,  pregnancy  must  be  terminated.  Every  method  of  feed- 
ing which  modern  nursing  can  suggest  should  be  exhausted ;  the 
patient  can  be  nourished  by  the  rectum  for  some  time,  by  the 
administration  of  nutrient  enemata. 

THE  MOTHER'S  BLOOD  DURING  PREGNANCY. — The  view  that 

the  blood  becomes  more  watery  during  pregnancy,  with  a  large 

number  of  white  corpuscles,  is  probably  not  true.     Aside  from 

the  condition  of  anaemia  which  follows  the  expulsion  of  the  foe- 

e  loss  of  blood  so  often  seen  during  labor,  the  healthy 

'Oman  may  be  said  to  be  in  a  condition  of  slight  ple- 


-•- 


DISORDERS   OF   THE   BLOOD    DURING   PREGNANCY.  185 

thora,  and  not  anaemia  Pernicious  anaemia  is  observed  at  times, 
and  forms  a  serious  complication  of  pregnancy.  The  symptoms 
of  this  condition  are  pallid  skin;  rapid  pulse,  dyspncea;  lassi- 
tude and  often  oedema.  Microscopic  examination  of  the  blood 
reveals  a  much  lessened  quantity  of  haemoglobin ;  red  corpuscles 
which  are  smaller  and  less  perfectly  formed  than  normally ;  and 
threads  of  fibrin  stretching  across  the  field  of  the  microscope. 
Blood  counts  show  a  lessened  number  of  red  corpuscles;  less- 
ened haemoglobin  percentage;  sometimes  increased  number  of 
white  cells.  When  not  pregnant,  these  patients  are  simply  chlor- 
otic ;  at  labor  haemorrhage  is  very  slight,  the  labor  pains  often 
deficient,  and  delivery  instrumental.  The  child  is  pale,  chlorotic 
and  of  feeble  vitality.  In  other  cases  the  child  is  strong,  its 
blood  being  found  normal  on  microscopic  examination. 

The  treatment  of  this  condition  is  best  accomplished  by  the 
persistent  administration  of  oxygen  by  inhalation,  and  arsenic  in 
small  doses,  with  nourishing  food.  Peptonized  milk,  soups, 
broths,  raw  meat  in  finely  chopped  and  seasoned  preparations,  and 
eggs  are  of  especial  value.  The  importance  of  oxygen  and  arsenic 
must  be  emphasized,  as  they  are  superior  to  iron  and  other  drugs. 

JAUNDICE  in  parturient  patients  may  be  hepatogenic  or  haemato- 
genic.  The  former  is  caused  by  catarrh  of  the  bile  ducts,  with 
occlusion  of  the  ducts  and  absorption  of  bile.  It  usually  accom- 
panies enteritis,  and  yields  to  treatment  addressed  to  the  secretion 
of  bile  and  the  intestinal  tract. 

Haematogenic  jaundice  results  from  an  acute  infection  affecting 
the  red  blood  corpuscles  and  causing  their  disintegration,  with 
absorption  of  haematin.  Acute  yellow  atrophy  of  the  liver  accom- 
panies profound,  malignant  jaundice,  and  is  considered  by  some 
to  be  caused  by  the  same  infection.  Haematogenic,  infectious 
jaundice  is  but  little  amenable  to  treatment ;  stimulants  and  tonics 
are  indicated  to  enable  the  patient  to  resist  the  infection. 

DISORDERS  OF  THE  SKIN  DURING  PREGNANCY.  —  Pregnant 
women  are  often  greatly  annoyed  by  discoloration  of  the  skin 
about  the  face  and  genital  organs  ;  the  facial  blemish  is  known  as 
the  "mask  of  pregnancy,"  and  is  usually  of  a  yellowish- brown 

8* 


1 86  MANUAL    OF    PRACTICAL    OBSTETRICS. 

color.  It  is  not  amenable  to  treatment  and  usually  disappears 
after  delivery. 

Pruritus  about  the  genital  organs  occasions  great  suffering  in 
some  cases.  Thorough  cleanliness  must  be  first  secured.  Hot  or 
cold  sponging ;  sitz  baths  of  warm,  but  not  hot  water;  anaesthetics, 
locally  applied,  and  the  galvanic  current  have  all  been  employed. 
But  little  more  than  palliation  can  be  expected  until  the  termina- 
tion of  pregnancy. 

VARICOSE  VEINS. — Few  women  pass  through  pregnancy  without 
dilatation  of  the  veins  of  the  lower  extremities,  and  often  the 
vulva  and  vagina.  Rupture  of  varicose  veins  of  the  vulva  and 
vagina  often  results  in  the  extravasation  of  blood  into  the  sub- 
mucous  tissue,  without  admitting  the  external  air.  When  dilata- 
tion is  excessive,  rupture  may  take  place  at  labor  or  when  very 
slight  violence  is  offered,  and  free  haemorrhage  result.  The  recum- 
bent posture  and  the  use  of  an  antiseptic  tampon  will  control  such 
haemorrhage. 

Varicose  veins  of  the  lower  extremities  occasion  great  discom- 
fort when  distension  is  excessive,  and  sudden  and  alarming 
haemorrhage  follows  rupture.  Before  rupture,  itching  and  burning 
sensations  and  often  an  eczematous  eruption  add  to  the  patient's 
discomfort.  Patients  suffering  from  varicose  veins  should  avoid 
constipation,  and  can  often  derive  comfort  from  some  form  of 
support.  An  elastic  stocking  or  flannel  bandage,  with  frequent 
bathing  in  a  saturated  solution  of  boracic  acid,  will  often  be  of 
great  service.  Such  patients  should  be  instructed  in  the  applica- 
tion of  a  compress  and  bandage,  and  cautioned  to  avoid  rupture 
of  a  vein  if  possible.  Garters  and  clothing  which  interfere  with 
the  circulation  in  the  lower  limbs  should  not  be  worn. 

HERNIA  OF  THE  PREGNANT  UTERUS. — In  rare  cases  the  preg- 
nant uterus  protrudes  in  the  umbilical,  crural,  or  inguinal  ring.  In 
umbilical  hernia  reposition  is  usually  not  difficult,  and  the  uterus 
is  retained  by  an  abdominal  bandage.  Abortion  or  Caesarean 
section,  if  the  foetus  be  movable,  is  indicated  in  these  cases,  with 
removal  of  the  uterus  if  it  cannot  be  returned  to  the  abdominal 
cavity. 


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FOREIGN  GROWTHS  IN  THE  PELVIS.  187 

PREGNANCY  COMPLICATED  BY  FOREIGN  GROWTHS  IN  THE 
UTERUS  AND  PELVIS. — Fibroid  tumors  of  the  pregnant  uterus 
usually  grow  softer  and  larger  as  pregnancy  progresses.  A  fibroid 
polyp  which  protrudes  from  the  os  may  be  removed,  but  a  less 
easily  accessible  tumor  should  not  be  disturbed.  Cancer  of  the 
cervix  of  the  pregnant  uterus  is  to  be  removed  as  in  the  non- 
pregnant.  Abortion  is  not  inevitable  upon  operation  in  such 
cases,  and  the  patient  should  not  be  allowed  to  suffer  by  delay. 

Still  more  imperative  is  the  obstetrician's  duty  in  pregnancy 
complicated  by  ovarian  tumors.  So  soon  as  a  diagnosis  can  be 
made  such  a  tumor  should  be  removed.  Under  antiseptic  pre- 
cautions the  prognosis  for  recovery  and  continuation  of  pregnancy 
is  excellent. 


CHAPTER    XXVIII. 

THE   SURGICAL   TREATMENT   OF   COMPLICATED    LABOR. 

IT  is  sometimes  necessary  to  terminate  labor  by  a  resort  to  surgi- 
cal operations.  Such  operations  have  for  their  object  the  saving 
of  the  life  of  the  mother  and  child,  or  saving  the  life  of  the 
mother  at  the  sacrifice  of  that  of  the  child. 

Under  the  first  heading  may  be  included  the  Csesarean  sec- 
tion, and  amputation  of  the  pregnant  uterus.  By  Csesarean  sec- 
tion is  understood  an  incision  into  the  abdomen,  an  incision  into 
the  uterus,  the  extraction  of  the  child  with  its  placenta  and  mem- 
branes, and  the  closure  of  the  uterus  by  suture.  This  operation 
is  of  great  antiquity,  taking  its  name  from  the  Roman  Caesar 
who  is  said  to  have  been  born  in  this  manner.  Since  antiseptic 
surgery  has  attained  its  present  perfection,  this  operation  has 
been  revived  with  excellent  results. 

The  indications  for  the  Caesarean  section  deserve  especial  con- 
sideration. The  child  must  be  living  and  viable;  the  mother 
must  not  be  infected  by  septic  infection,  nor  can  her  uterus  be 
the  seat  of  a  pathological  process  which  would  prevent  a  uterine 
incision  from  healing.  There  must  be  such  disproportion 
between  her  birth-canal  and  the  size  of  her  foetus  that  the 
delivery  of  the  latter  alive  is  impossible.  The  consent  of  the 
mother,  or,  in  the  event  of  her  being  unconscious,  of  her  nearest 
relative,  must  be  secured.  When  these  conditions  are  present 
the  success  of  the  operation  will  depend  upon  three  grounds : 

i st.  A  knowledge  and  faithful  application  of  antiseptic  pre- 
cautions. 

2nd.  The  co-operation  of  at  least  one  intelligent  assistant. 

3d.  Adequate  closure  of  the  uterine  incision. 

In  regard  to  the  first,  the  operator  should  thoroughly  antisepti- 
188 


THE    SURGICAL    TREATMENT   OF    COMPLICATED    LABOR.       189 

cize  his  hands,  instruments  and  appliances.  The  abdomen  of 
the  patient  should  be  scrubbed  with  soap  and  water,  washed  with 
ether  and  then  with  a  solution  of  bi-chloride  of  mercury,  one  to 
one  thousand.  No  antiseptic  fluid  should  be  introduced  within 
the  abdominal  cavity.  If  it  is  necessary  to  wash  out  the  abdo- 
men, it  should  be  done  with  boiled  water  at  a  temperature  of 
100.  If  the  interior  of  the  uterus  is  found  in  a  condition  re- 
quiring disinfection,  this  can  best  be  accomplished  by  tamponing 
it  with  iodoform  gauze,  the  ends  of  the  tampon  emerging 
through  the  vagina.  The  assistant,  whose  co-operation  is 
essential,  has  for  his  function  compression  of  the  uterus  to  pre- 
vent haemorrhage.  He  should  also  observe  the  strictest  antisep- 
tic precautions  by  especial  attention  to  cleansing  his  hands. 

The  question  of  the  method  of  closing  the  uterine  incision  has 
occasioned  much  discussion,  and  seems  finally  to  have  reached  a 
satisfactory  solution.  When  the  Caesarean  operation  was  revived 
by  Saenger,  it  was  thought  necessary  to  close  the  muscular  tissues 
of  the  uterus,  and  also  the  peritoneum  covering  that  organ,  by  a 
separate  line  of  sutures.  While  this  is  undoubtedly  a  safe  and  cor- 
rect method  of  operating,  yet  others  have  performed  the  opera- 
tion successfully  by  including  the  peritoneum  and  muscular  tissue 
in  one  suture,  approximating  the  edges  of  the  incision  with  great 
care.  As  first  performed,  the  sutures  during  the  operation  were 
not  passed  through  the  decidua  lining  the  uterus,  but  in  various 
operations  this  has  been  included  in  the  sutures  without  disastrous 
results.  It  is  of  the  greatest  importance,  however,  that  a  suffi- 
cient number  of  sutures  be  used  to  solidly  approximate  the  edges 
of  the  incision.  It  is  of  paramount  importance  that  the  edges 
of  the  peritoneum  covering  the  uterus  be  brought  carefully  into 
apposition  so  that  they  may  unite  perfectly. 

The  material  employed  for  sutures  may  be  silver  wire,  catgut, 
or  silk.  If  catgut  be  employed,  none  but  the  best  quality  should 
be  used,  as  otherwise  septic  infection  or  loosening  of  the  edges  of 
the  incision  may  result  disastrously  to  the  patient.  If  possible, 
the  patient  should  be  prepared  for  operation  in  the  manner  usual 
before  all  abdominal  sections.  No  solid  food  should  be  taken 


1 90  MANUAL   OF   PRACTICAL   OBSTETRICS. 

for  a  day  before  the  operation,  the  bowels  should  be  thoroughly 
emptied,  several  antiseptic  vaginal  douches  should  be  given,  and 
if  a  suspicious  discharge  from  the  uterus  persists,  the  vagina 
should  be  tamponed  at  the  time  of  operation  with  iodoform 
gauze.  Beside  the  chief  assistant  already  mentioned,  two  others 
will  be  found  useful,  with  a  trained  nurse.  One  of  the  assistants 
should  give  the  anaesthetic,  the  other  should  be  ready  to  devote 
his  entire  attention  to  the  resuscitation  of  the  child. 

The  instruments  needed  are  a  scalpel,  several  pairs  of  haemo- 
static forceps,  two  sizes  of  curved  needles,  a  needle-holder,  and 
a  piece  of  stout  rubber  tubing  as  large  as  the  little  finger,  two  or 
three  feet  in  length.  If  the  patient  have  no  bronchitis  or  dis- 
ease of  the  kidneys,  ether  may  be  employed  as  an  anaesthetic, 
but  should  either  of  these  complications  be  present,  chloroform 
may  be  used.  At  the  time  of  operation,  the  nurse  should  have 
ready  bottles  filled  with  hot  water;  whisky  or  brandy,  digitalis, 
aromatic  spirits  of  ammonia,  fluid  extract  of  ergot,  or  a  solution 
of  ergotine  especially  prepared  for  hypodermic  injection,  and  a 
solution  of  morphia.  The  usual  basins  and  pitchers  for  washing 
sponges  and  for  irrigating  the  abdominal  cavity  should  be  in 
readiness.  It  is  well  to  have  also  a  fountain  syringe  with  a  suit- 
able tube  for  giving  a  vaginal  douche.  In  addition,  there  should 
be  in  readiness  a  small  tub  filled  with  hot  water  for  use  in  resusci- 
tating the  child.  The  patient  having  been  anaesthetized,  the 
chief  assistant  stands  beside  the  operator  with  the  rubber  tubing 
already  mentioned  within  convenient  grasp.  The  operator  will 
desire  to  incise  the  uterus  upon  its  anterior  aspect  about  midway 
between  the  fundus  and  the  lower  uterine  segment.  The  period 
of  labor  chosen  for  operation  is  preferably  the  end  of  the  first 
stage  when  dilatation  is  nearly  complete.  An  abdominal  incision 
of  from  three  to  five  inches  should  then  be  made  over  the  portion 
of  the  uterus  which  the  operator  wishes  to  enter.  The  peritoneum 
having  been  incised,  two  courses  are  then  open  for  the  operator ; 
one  is  to  enlarge  the  incision  sufficiently  to  turn  the  uterus  for- 
ward out  of  the  abdominal  cavity;  the  other  is  to  incise  it  as  it 
lies  in  the  abdomen.  If  the  uterus  is  turned  out,  towels  which 


THE    SURGICAL   TREATMENT   OF   COMPLICATED   LABOR.        191 

have  previously  been  boiled  and  wrung  out  of  freshly  boiled 
warm  water  should  be  laid  over  the  intestines  behind  the  uterus 
and  upon  the  abdomen  so  that  the  uterus  may  rest  upon  them. 

Two  methods  of  checking  haemorrhage  are  available  at  the  time 
of  the  uterine  incision.  One  consists  in  drawing  the  elastic  tube 
tightly  about  the  uterus  at  the  junction  of  the  cervix  and  the 
body;  the  other  is  grasping  the  uterus  with  both  hands  at  the 
region  indicated,  while  the  incision  is  made.  The  former  pro- 
cedure was  followed  by  Saenger  with  good  results;  the  latter  has 
been  successfully  employed  upon  several  occasions.  When  the 
uterus  has  been  exposed,  and  the  site  of  the  incision  determined, 
and  when  the  chief  assistant  is  ready  to  check  the  haemorrhage 
either  by  the  tubing  or  by  his  hands,  the  operator  opens  the 
uterus  by  an  incision  from  three  to  four  inches  in  length,  ruptures 
the  membranes,  feels  for  one  of  the  foetal  limbs,  and  extracts  the 
child  as  soon  as  possible.  The  cord  should  be  immediately  tied 
and  cut,  and  the  child  given  to  a  second  assistant,  who  devotes 
his  energies  to  establishing  respiration.  The  operator  should  then 
peel  off  the  placenta  and  membranes  and  deliver  them.  If  the 
placenta  and  lining  membranes  of  the  uterus  are  found  to  be 
healthy,  the  uterus  may  be  immediately  closed  by  two  rows  of 
sutures,  one  through  the  muscular  substance  at  intervals  of  not 
more  than  half  an  inch,  the  other  row  of  sutures  passing  through 
the  peritoneum.  In  the  first,  the  needle  should  not  pass  through 
the  lining  membrane  of  the  uterus  if  possible,  but  should  enter 
the  muscular  substance,  emerging  just  above  the  decidua.  For 
the  second,  or  peritoneal  suture,  a  continuous  suture  of  catgut 
may  be  employed,  if  desired.  When  the  uterus  has  been  properly 
sutured,  pressure  made  by  the  hand  of  the  chief  assistant  or  by 
the  rubber  ligature  should  be  relaxed.  If  an  atonic  condition  of 
the  uterine  muscle  is  present,  ergot  or  ergotine  may  be  given  by 
hypodermic  injection.  Should  this  prove  ineffectual,  the  uterus 
may  be  tamponed  through  the  vagina  with  iodoform  gauze.  If 
amniotic  fluid  has  escaped  into  the  abdominal  cavity,  free  irriga- 
tion with  boiled  water,  at  a  temperature  of  100,  should  be  em- 
ployed. The  abdomen  is  then  closed  in  the  usual  manner,  a 


192  MANUAL    OF   PRACTICAL    OBSTETRICS. 

firm  antiseptic  dressing  placed  over  the  incision,  and  the  patient 
treated  in  the  manner  usual  after  an  abdominal  section. 

The  placenta  will  often  be  found  directly  in  the  line  of  the  inci- 
sion. When  this  occurs,  the  operator  cannot  avoid  incising  the 
placenta  and  causing  free  haemorrhage.  He  should  not,  however, 
hesitate  to  incise  the  placenta,  rapidly  extract  the  child  and  sep- 
arate and  deliver  the  placenta,  when  the  uterus  will  contract  and 
haemorrhage  cease.  Should  the  case  proceed  favorably,  the  pa- 
tient will  have  the  usual  phenomena  of  the  lying-in  period.  The 
secretion  of  milk  will  be  normally  established,  the  involution  of 
the  uterus  will  proceed  with  very  little  deviation  from  its  usual 
course,  and  no  difference  should  be  observed  in  the  general 
phenomena  of  the  patient's  recovery.  In  two  weeks  the  stitches 
may  be  removed  from  the  abdominal  incision,  and  in  a  month  the 
patient  may  go  about,  wearing  an  abdominal  bandage.  The  lochia 
are  usually  red  in  these  cases,  and  less  abundant  than  after  normal 
labor.  The  child  presents  upon  examination  a  notable  absence  of 
the  configuration  of  the  head  usually  seen  after  labor  It  is  differ- 
ent, however,  in  no  other  way  from  the  child  born  naturally. 

A  number  of  cases  are  on  record  where  the  Caesarean  operation 
has  been  performed  twice,  occasionally  three  times,  upon  the  same 
patient.  When  the  uterus  is  examined  in  such  instances,  no  traces 
can  be  found  of  the  former  incision.  If  catgut  be  used  it  will  have 
been  absorbed.  Silk  is  sometimes  absorbed  and  sometimes  encysted ; 
silver  wire  of  course  remains,  but  so  far  as  any  difference  in  the 
uterine  tissue  is  concerned,  the  union  is  commonly  perfect. 

The  prognosis  for  the  mother  and  child  in  Caesarean  section, 
when  performed  as  we  have  indicated,  gives  nine  chances  out  of 
ten  for  recovery  to  both. 

AMPUTATION  OF  THE  PREGNANT  UTERUS. — When  the  body  of 
the  uterus  is  the  site  of  a  pathological  process  so  that  its  tissues 
when  incised  will  not  heal  kindly,  it  is  best  to  amputate  the 
uterus  at  the  cervix.  Thus,  in  cases  of  fibroids,  where  the  inci- 
sion would  pass  through  a  fibroid  in  performing  Caesarean  sec- 
tion, necrosis  and  septic  absorption  would  result  if  the  usual 
Caesarean  operation  were  employed.  In  cases  where  the  pelvis  is 


THE   SURGICAL   TREATMENT   OF   COMPLICATED   LABOR.        193 

so  small  that  Etnbryotomy  cannot  be  performed  without  great 
danger  to  the  mother,  if  the  foetus  be  dead,  and  especially  if  sep- 
tic infection  has  already  begun,  the  uterus  should  be  amputated. 
The  operation  is  made  with  the  precautions  which  have  already 
been  described  as  regards  antisepsis.  An  incision  is  made  over 
the  uterus,  and  the  latter  is  tipped  forward  and  out  of  the  abdom- 
inal  cavity.  It  may  then  be  encircled  by  the  elastic  ligature, 
and  steel  needles  resembling  knitting-needles  be  thrust  through 
the  ligature  and  cervix  to  keep  the  former  from  slipping  when  the 
uterus  is  amputated.  The  uterus  should  then  be  incised,  and  the 
child  and  its  appendages  removed.  Instead  of  closing  the  womb 
by  suture,  as  in  the  Caesarean  operation,  the  operator  then  ampu- 
tates the  uterus  just  above  the  elastic  ligature.  The  peritoneal 
covering  of  the  uterus  is  then  stitched  over  the  stump,  the  stump  is 
brought  up  to  the  lower  end  of  the  abdominal  incision,  the  perito- 
neum is  closed  down  to  and  around  the  stump,  leaving  the  cut 
surface  above  the  line  of  peritoneal  suture.  The  abdominal  inci- 
sion is  then  closed  from  above  downward,  the  stump  of  the  uterus 
remaining  at  the  lower  end  of  the  abdominal  incision.  If  oozing 
from  the  stump  persists  it  may  be  powdered  with  iodoform  and 
plaster  of  Paris.  If  oozing  be  not  present,  iodoform  should  be 
thoroughly  sprinkled  upon  it,  and  an  antiseptic  dressing  be  placed 
over  it.  The  theory  of  the  operation  is  that  the  stump  of  the  uterus 
will  atrophy,  contract  and  heal  by  granulation  at  the  lower  edge  of 
the  abdominal  incision.  This  process  is  slower  than  union  in  the 
Caesarean  section,  and  destroys  any  future  possibility  for  repro- 
duction on  the  part  of  the  patient.  Various  other  methods  for 
controlling  the  haemorrhage  and  ligating  the  stump  have  been  em- 
ployed. The  stump  has  also  been  ligated,  its  peritoneal  covering 
drawn  over  it,  and  it  has  been  dropped  into  the  abdominal  cav- 
ity, but  the  method  described  has  furnished  the  best  results,  and 
is  most  practicable  in  the  greatest  number  of  cases.  The  chief 
dangers  following  amputation  of  the  uterus  are  haemorrhage  and 
septic  absorption.  Of  these,  the  latter  can  almost  invariably 
be  avoided  by  proper  antisepsis  ;  the  former  is  occasionally  be- 
yond control. 
9 


CHAPTER    XXIX. 

THE   SURGICAL   TREATMENT   OF   COMPLICATED   LABOR. 

EMBRYOTOMY. — When  the  foetus  is  so  much  larger  than  the 
birth-canal  of  the  mother  that  it  cannot  be  delivered  without 
sacrificing  its  own  life  and  endangering  that  of  the  mother,  one 
of  two  procedures  is  inevitable,  either  to  remove  the  fcetus  by 
the  Caesarean  section,  or  amputation  of  the  pregnant  uterus,  or 
to  deliver  the  fcetus  by  lessening  its  size.  The  latter  sacrifices 
the  life  of  the  fcetus,  if  it  be  not  already  dead  through  pressure 
of  the  uterus  in  efforts  made  to  deliver  the  child.  When  the 
fcetus  has  already  perished,  the  duty  of  the  obstetrician  is  to 
deliver  it  through  the  natural  channels,  having  previously  lessened 
its  diameters.  As  any  procedure  which  makes  the  fcetus  smaller 
accomplishes  this  by  cutting  the  child,  such  a  procedure  is 
termed  Embryotomy.  Thus,  Embryotomy  embraces  piercing 
the  head,  spinal  column,  thorax  or  abdomen,  allowing  the  body 
of  the  child  to  partially  collapse,  thus  reducing  its  size.  Em- 
bryotomy would  also  include  amputation  of  fcetal  members  in 
cases  where  a  fcetus  becomes  impacted  in  a  transverse  position. 
The  portion  of  the  fcetus  which  is  most  frequently  pierced  to 
lessen  its  size  is  the  fcetal  head,  and  a  separate  name  has  been 
given  to  the  operation  of  piercing  the  head  and  evacuating  a 
portion  of  its  contents,  namely,  Craniotomy. 

As  Craniotomy  is  the  most  frequent  operation  for  lessening  the 
size  of  the  fcetus,  it  may  be  considered  first.  There  are  prac- 
tically two  methods  for  lessening  the  size  of  the  fcetal  head ;  one 
consists  in  piercing  the  skull  with  a  sharp-edged  instrument, 
allowing  the  brain  and  its  fluids  to  escape  by  the  pressure  of  the 
uterus  upon  the  head;  the  other  embraces  the  removal  of  a 
portion  of  the  cranial  bones,  leaving  a  permanent  opening  into 
194 


THE    SURGICAL   TREATMENT   OF   COMPLICATED    LABOR.        195 

the  skull  through  which  the  brain  is  evacuated  by  the  injection 
of  fluid.  The  second  operation  is  done  by  means  of  a  trephine 
resembling  that  used  in  general  surgery,  but  with  a  longer  handle. 
The  instruments  employed  for  simply  piercing  the  head  are  based 
upon  the  principle  of  a  pair  of  sharp-pointed  scissors  having  the 
outer  edge  of  the  blades  near  the  tips  ground  to  a  cutting  edge  (Fig. 
94).  The  scissors  are  introduced  and  the  handles  separated,  thus 
causing  the  outer  edges  of  the  blades  to  enlarge  the  opening  made 


FIG.  94. 


SMELLIE'S  SCISSORS. 

by  the  points.  The  scissors  may  then  be  turned  at  right  angles 
to  the  direction  of  insertion,  and  the  blades  opened  a  second 
time,  when  a  cross-shaped  incision  will  result.  Other  more 
elaborate  perforators  are  based  upon  the  same  principle  as  the 
perforating  scissors  (Fig.  95). 

An  indication  for  Craniotomy  exists  in  a  case  where  the  foetus 


FIG.  95. 


BLOT'S  PERFORATOR. 


is  too  large  for  the  mother's  birth-canal,  is  presenting  by  the 
head,  and  has  already  died.  In  a  similar  case  where  the  foetus 
is  living,  the  patient  and  her  friends  must  choose  between  a 
Caesarean  operation  and  the  destruction  of  a  living  child  by 


196  MANUAL   OF    PRACTICAL   OBSTETRICS. 

Craniotomy.  The  opinion  is  gaining  ground  among  the  medical 
profession  that  Craniotomy  upon  the  living  child  is  unjustifiable, 
and  this  opinion  is  likely  to  obtain  a  still  firmer  footing  as  physi- 
cians become  more  familiar  with  obstetric  surgery.  It  is  always 
well  to  respect  the  beliefs  of  the  parents  of  the  child  regarding 
religious  observances,  as  many  persons  discourage  Craniotomy 
upon  theological  grounds. 

It  should  be  borne  in  mind  that  Embryotomy  requires  antisep- 
tic precautions  as  complete  and  as  carefully  carried  out  as  an 
abdominal  incision.  A  vaginal  douche  of  bi-chloride,  one  to 
five  thousand,  should  be  given,  the  hands  and  arms  of  the  opera- 
tor should  be  disinfected,  his  instruments  cleansed  with  boiling 
water  and  immersed  in  a  five  per  cent,  solution  of  carbolic  acid, 
or  a  two  per  cent,  solution  of  creolin.  The  patient  should  then 
be  anaesthetized,  placed  across  a  bed  or  upon  a  table,  and  the 
operator  should  ascertain  the  exact  position  of  the  head  by  a 
thorough  examination. 

If  it  is  decided  to  pierce  the  skull  without  making  a  perma- 
nent opening,  the  fingers  of  one  hand  should  be  introduced  as  a 
guide,  and  with  the  other  the  point  of  the  perforator  should  be 
firmly  but  gently  forced  through  the  foetal  skull.  It  is  well  not 
to  enter  the  head  in  a  line  of  a  suture,  but  to  make  an  incision 
through  bony  tissue.  The  blades  of  the  perforator  should  then  be 
separated,  the  instrument  turned  at  a  right  angle,  and  the  blades 
again  opened  as  has  been  described.  The  case  then  should  be  left 
to  the  expulsive  efforts  of  the  mother,  the  expectation  being  that 
pressure  of  the  uterus  will  force  out  the  brain  and  its  contents,  and 
then  collapse  the  head.  Should  the  mother's  expulsive  forces  fail, 
the  forceps  may  sometimes  be  used  to  advantage  in  completing 
delivery.  If  the  head  be  well  ossified,  especially  at  the  base  of 
the  skull,  the  simple  perforation  may  be  followed  by  the  use  of  an 
instrument,  designed  to  crush  in  the  head  by  strong  pressure, 
known  as  a  cephalotribe  (Fig.  96).  This  is  nothing  more  than  a 
strong  pair  of  forceps  with  suitable  apparatus  for  forcibly  bringing 
the  blades  in  apposition.  A  better  procedure,  however,  than  in- 
.  cising  the  skull  is  removing  a  portion  of  bone  by  the  trephine. 


THE    SURGICAL    TREATMENT   OF   COMPLICATED   LABOR.        197 

Two  sorts  of  obstetric  trephines  are  in  use,  the  straight  and  the 
curved.  Of  these  the  straight  trephine  is  the  better  because  of 
its  simple  construction  and  the  ease  with  which  it  can  be  taken 

FIG.  96. 


LUSK'S  CEPHALOTRIBE. 

apart  and  disinfected.  By  removing  the  screw  button  at  the  end 
of  the  trephine,  the  instrument  can  be  separated  into  its  three  por- 
tions, each  of  which  is  readily  cleansed  (Fig.  97).  In  addition 

FIG.  97. 


MARTIN'S  STRAIGHT  TREPHINE. 

to  the  trephine,  there  is  needed  to  evacuate  the  brain  a  tube  of 
metal  or  hard  rubber  sufficiently  strong  to  be  passed  freely 
around  the  interior  of  the  skull,  thus  breaking  up  the  brain  and 
its  membranes.  To  this  tube  should  be  attached  a  piece  of  rub- 
ber tubing  through  which  an  antiseptic  solution  may  be  injected 
with  considerable  force  by  a  strong  piston-syringe.  After  the 
head  has  been  opened  and  the  brain  evacuated,  there  is  required 
for  the  extraction  of  the  head  some  instrument  one  of  whose 
blades  shall  pass  within  the  opening  made  by  the  trephine  while 
the  other,  applied  upon  the  external  surface  of  the  skull,  fits  into 
the  first  by  a  firm  screw  upon  the  handles,  thus  securing  a  sure 
grasp  upon  the  head.  This  instrument  has  a  pelvic  curve  like 


198 


MANUAL   OF    PRACTICAL   OBSTETRICS. 


that  of  the  forceps,  and  traction  is  made  by  it  in  the  axis  of  the 
pelvis  as  in  axis-traction-forceps.  As  the  head  descends,  pressure 
of  the  walls  of  the  pelvis  collapses  the  head,  and  it  emerges  drawn 
out  in  a  shape  somewhat  resembling  a  sugar-loaf  (Fig.  98).  The 


FIG. 


FCETAL  HEAD  TREPHINED  AND  DELIVERED  BY  CRANIOCLAST. 

procedure  of  extracting  the  head  and  collapsing  it  in  this  manner 
is  known  as  Cranio-Clasis,  and  an  instrument  designed  for  this 
purpose  is  called  a  Cranioclast  (Fig.  99).  The  instrument  will 
be  better  understood  by  reference  to  (Fig.  100)  which  represents 
the  Cranioclast  devised  by  Carl  Braun  of  Vienna. 

To  contrast  the  two  methods  of  lessening  the  size  of  the  head 


THE    SURGICAL   TREATMENT   OF   COMPLICATED    LABOR.        199 

we  may  repeat  that  the  skull  may  be  entered  by  an  incision  through 
the  bone  with  a  perforator.  A  pair  of  strong  compressing  forceps, 
with  a  compressing  screw  at  the  extremity  of  the  handles,  may 
then  be  employed  to  crush  the  head  and  extract  it.  This  is  known 

FIG.  99. 


GRASPING  THE  HEAD  WITH  THE  CRANIOCLAST. 


as   Cephalo-Tripsy,   and   the   compressing   forceps   is   named  a 
Cephalotribe. 

FIG.  100. 


*    BRAUN'S  CRANIOCLAST. 

On  the  other  hand,  the  skull  may  be  trephined  and  the  brain 
evacuated,  and  an  instrument  employed  to  make  traction,  one 
blade  of  which  is  inserted  through  the  trephine  opening,  the 


200 


MANUAL   OF    PRACTICAL   OBSTETRICS. 


other  grasping  the  head  externally,  while  compression  is  made 
by  a  strong  compressing  screw.       Traction  in  the  axis  of    the 


FIG.  101. 


CRANIOTOMY  WITH  THE  SIMPLE  PERFORATOR. 
FIG.  102. 


CRANIOTOMY  WITH  THE  TREPHINE. 


THE    SURGICAL   TREATMENT   OF   COMPLICATED   LABOR.        2OI 

pelvis  results  in  the  collapse  of  the  head  through  pressure  of  the 
pelvic  walls.  This  is  Cranio-Clasis,  and  the  instrument  is  a 
Cranioclast. 

In  cases  where  twins  have  become  impacted  in  the  uterus,  and 
one  or  both  have  perished  before  assistance  arrives,  it  may  be 
necessary  to  decapitate  the  child  already  partially  born,  to  relieve 
the  mother.  In  cases  of  transverse  presentation,  where  the  uterus 
is  in  a  condition  of  rigid  contraction  known  as  uterine  tetanus, 
it  may  not  be  safe  to  attempt  to  make  version  because  of  the 
danger  of  uterine  rupture.  There  remains  then  nothing  to  do 
but  to  decapitate  the  foetus  and  remove  the  body  and  head 
separately. 

In  transverse  positions,  amputation  of  the  head  may  be  per- 
formed by  passing  a  heavy  cord  about  the  neck  and,  by  a  sawing 
motion,  cutting  slowly  through  the  tissues  (Fig.  103).  When  the 
child's  spinal  column  is  reached,  if  the  cord  be  guided  to  the  in- 
tervertebral  cartilage,  decapitation  may  be  accomplished  without 
especial  difficulty.  Should  the  cartilage  not  be  readily  found,  a 
cutting  instrument  may  then  be  employed  to  finish  the  decapita- 
tion. A  very  convenient  and  safe  instrument  for  this  procedure  is 
the  hook  devised  by  Carl  Braun  (Fig.  104).  This  hook  is  passed 
over  the  child's  neck,  drawn  strongly  downward,  and  a  rotary 
movement  from  side  to  side  kept  up  until  finally  the  tissues  are 
completely  severed.  It  is  best  to  employ,  if  possible,  some  instru- 
ment or  device  having  no  sharp  cutting  edge,  as  the  danger  of 
wounding  the  soft  tissues  of  the  mother  is  great.  Braun's  hook  is 
carefully  polished,  and  presents  no  edge  which  should  injure  the 
maternal  tissues  (Fig.  105).  In  cases  of  impacted  foetus  where  the 
body  of  the  child  is  already  born,  decapitation  may  be  accomplished 
by  the  use  of  a  pair  of  ordinary  strong  scissors  and  a  piece  of 
rubber  tubing.  The  tubing  should  be  passed  about  the  neck  and 
tied,  forming  a  circle  around  the  child's  neck.  Its  purpose  is  to 
serve  as  a  guard  against  cutting  too  high  and  injuring  the  tissues 
of  the  mother.  Guiding  the  scissors  with  the  left  hand,  with  the 
right  hand  the  tissues  are  severed  just  beneath  the  constricting  tube, 
and  thus  decapitation  is  accomplished. 


202 


MANUAL   OF   PRACTICAL    OBSTETRICS. 


Ingenious  instruments  have  been  devised  by  which  a  cutting 
edge,  in  the  form  of  an  ecraseur  or  cutting  wire,  may  be  passed 
about  the  head,  but  such  instruments  are  more  complicated  and 
less  safe  than  the  simple  devices  described. 

In  cases  of  hydrocephalus,  when  the  child  presents  by  the 

FIG.  103. 


DECAPITATION;  TIGHTENING  A  CORD  AROUND  THE  NECK. 

breech,  the  progress  of  birth  will  often  cease  with  the  efforts 
to  expel  the  head.  It  is  desirable  in  such  cases  to  drain  the  sub- 
arachnoid  spaces  to  lessen  the  size  of  the  head  ;  an  opening  may 
be  made  into  the  spinal  column,  the  soft  tissues  having  first  been 
incised  to  permit  of  easy  access  to  the  vertebrae. 


SURGICAL   TREATMENT   OF   COMPLICATED    LABOR.        203 

By  evisceration  is  understood  that  form  of  embryotomy  which 
opens  the  abdominal  or  thoracic  cavity  of  the  foetus,  allowing  the 
escape  of  blood  and  other  fluids  contained  in  these  cavities,  and 


FIG.  104. 


FIG.  105. 


DECAPITATION  WITH  BRAUN'S  HOOK. 


BRAUN'S  DECAPITATION 
HOOK. 


oftentimes  the  removal  of  the  viscera  themselves.     This  is  usually 
readily  accomplished  by  incising  the  walls  of  the  cavity.     It  is 


204 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


sometimes  best  to  eviscerate  the  thorax  by  opening  the  abdomen 
below  the  diaphragm,  rupturing  the  diaphragm,  and  extracting 
the  lungs  and  heart  from  the  opening  thus  made. 

Embryotomy  requires  especial  caution  as  regards  antisepsis. 
It  is  well  not  only  to  cleanse  instruments  and  hands,  but  also  to 
wash  out  a  cavity  opened,  by  an  antiseptic  solution.  In  cases 
where  the  foetus  has  died  it  may  contain  in  its  body  sources  of 

FIG.  106. 


TARNIER'S  BASIOTRIBE. 

infection,  and  hence  its  tissues  should  be  antisepticized  at  the 
moment  when  the  body  is  opened. 

Craniotomy  upon  the  after-coming  head  is  sometimes  indicated  in 
cases  where  the  head  becomes  impacted  at  the  moment  of  delivery 
in  breech  presentation  (Fig.  106).  It  is  usually  most  convenient 
to  enter  the  skull  through  the  foramen  magnum,  the  head  having 
been  brought  as  far  down  as  possible  by  traction  upon  the  trunk. 
After  the  evacuation  of  the  skull,  delivery  will  be  usually  accom- 
plished most  easily  by  the  use  of  the  cephalotribe.  It  may  some- 
times be  necessary  to  enter  the  skull  through  the  roof  of  the  foetal 
mouth. 

MINOR  OBSTETRIC  SURGERY  IN  DELAYED  LABOR. — In  cases 
where  delay  in  labor  occurs  through  rigidity  of  the  os  and  cervix, 


THE   SURGICAL   TREATMENT   OF   COMPLICATED   LABOR.        205 

dilation  may  be  accomplished  by  stretching,  with  the  fingers  or 
Barnes'  rubber  bags,  or  by  majcing  multiple  shallow  incisions  in 
the  os  and  then  dilating.  Especial  precautions  regarding  anti- 
sepsis are  required  in  these  cases,  for  wounded  surfaces  in  the  os 
and  cervix  become  easily  infected.  By  multiple  incisions  exten- 
sive laceration  of  the  cervix  may  often  be  prevented. 


CHAPTER  XXX. 

THE  PUERPERAL  STATE. 

THE  accomplishment  of  labor  marks  the  beginning  of  what 
is  known  as  the  lying-in  period,  or  puerperium,  or  the  puer- 
peral state.  By  this  is  understood  the  time  in  which  the 
woman  is  recovering  from  the  effects  of  her  labor.  It  will 
be  seen  that  no  limit  can  be  set  in  all  cases  for  the  puer- 
peral period.  Thus,  the  savage  woman  recovers  from  labor  suffi- 
ciently to  resume  her  usual  avocations  in  a  few  days,  while  her 
civilized  but  weaker  sister  requires  several  months  to  fully  recover 
from  parturition.  The  lying-in  period  applies  especially  to  the 
time  during  which  the  patient  is  in  bed,  but  also  the  time  elaps- 
ing before  the  patient  engages  actively  in  her  former  pursuits. 
The  phenomena  of  the  puerperal  period  are  those  connected  with 
the  process  by  which  the  uterus  and  the  entire  genital  tract  are 
reduced  in  size  from  their  hypertrophied  condition  at  labor  to 
their  normal  proportions.  Together  with  this  process,  called 
involution,  the  abdominal  muscles  of  the  patient,  which  have 
been  strained  and  distended  during  the  pregnancy,  assume  their 
former  consistence  and  contractile  power.  The  hypertrophies 
which  have  existed  in  the  secretory  and  glandular  organs  of 
the  patient  gradually  give  place  to  the  usual  conditions  obtain- 
ing in  these  parts.  Together  with  these  changes,  which  may 
be  styled  retrograde  or  absorptive  changes,  there  occurs  the 
establishment  of  a  new  function,  namely,  lactation,  or  the  secre- 
tion of  milk. 

It  is  evident  that  the  first  set  of  changes  mentioned,  namely, 
involution,  results  in  the  formation  of  a  large  amount  of  material 
to  be  removed  from  the  body.  If  organs  have  hypertrophied  by 
the  multiplication  of  cellular  elements  and  the  aggregation  of 
tissues,  a  normal  condition  of  these  organs  can  only  be  reached 
206 


THE    PUERPERAL   STATE.  207 

by  eliminating  the  excess  of  material.  Thus,  the  uterine  muscle 
and  the  enlarged  and  multiplied  glands  of  the  lining  membrane 
of  the  uterus  are  lessened  in  size  by  a  process  closely  resembling 
that  of  fatty  degeneration.  The  material  produced  by  this  degen- 
eration is,  a  portion  of  it,  oxygenated  in  the  patient's  blood  by 
respiration,  while  the  greater  part  of  it  is  removed  from  the  body 
by  the  different  emunctories.  The  presence  in  the  blood  of  this 
fatty  material  produces  an  increased  amount  of  bodily  heat, 
resulting  oftentimes  in  a  slight  and  habitual  rise  of  temperature 
during  the  week  or  ten  days  of  the  puerperal  period.  Thus,  the 
average  temperature  of  the  healthy  lying-in  woman  is  often  one 
hundred  degrees  instead  of  ninety-eight  and  five-tenths.  In  some 
cases,  the  patient  seems  to  take  care  of  this  material  without  dis- 
turbance of  temperature  and  with,  possibly,  a  different  mode  of 
elimination.  Together  with  the  breaking  down  of  hypertrophied 
tissue  there  comes  a  process  of  multiplication  of  red  blood  cor- 
puscles which  restores  to  the  blood  its  losses  at  labor. 

When  once  the  fatigue  of  labor  has  been  surmounted,  a 
sense  of  physical  comfort  and  an  increase  in  appetite  com- 
monly occur,  which  persist  through  the  puerperal  period.  The 
lacerations  in  the  genital  tract  heal  during  this  time;  deposits 
of  pigment  upon  the  face  or  other  portions  of  the  body  are 
slowly  absorbed  and  destroyed,  and  oftentimes  a  gain  in  weight 
and  an  increase  in  the  development  of  the  woman  follow  parturi- 
tion. While  the  breasts  have  become  somewhat  hypertrophied  by 
a  turgid  condition  of  the  mammary  glands  during  pregnancy,  yet 
the  formation  of  breast-milk  does  not  take  place  until  a  number 
of  hours,  or  possibly  two  or  three  days  after  delivery.  The  milk 
may  then  come  into  the  breasts,  as  it  is  sometimes  said,  "  with  a 
rush."  The  breasts  become  distended,  reddened  from  a  general 
hyperaemia,  and  frequently  the  neighboring  lymphatics  show  a 
temporary  engorgement.  The  over-distended  tissues  of  the  peri- 
neum and  pelvic  floor  regain  their  elasticity  to  a  considerable 
extent.  There  always  remains,  however,  a  certain  degree  of 
dilatation— sufficient  to  make  a  diagnosis  of  a  previous  parturition 
possible. 


208  MANUAL   OF   PRACTICAL   OBSTETRICS. 

A  peculiar  condition  of  receptivity  to  certain  infections  seems 
to  obtain  during  the  lying-in  period.  Thus,  the  exanthematous 
diseases  are  more  easily  contracted  by  lying-in  women  than  by 
others.  Septic  infection  from  polluted  air,  or  from  unclean  sur- 
roundings, is  also  readily  absorbed.  While  this  may  be  explained 
in  part  by  the  lacerated  surfaces  of  the  genital  tract,  infection 
from  a  contaminated  atmosphere  is  sufficiently  common  to  illus- 
trate the  patient's  receptive  condition.  The  nervous  system, 
which  has  been  so  severely  taxed  during  parturition,  shows  imme- 
diately afterward  an  unstable  state  which  renders  the  patient  easily 
disturbed  by  emotion.  Thus  any  cerebral  disturbance  results  in 
a  considerable  derangement  of  temperature,  or,  oftentimes,  in 
serious  interference  with  the  function  of  lactation. 

The  treatment  of  the  puerperal  period  consists  in  surrounding 
the  patient  with  such  an  environment  that  her  dangers  of  infection 
shall  be  reduced  to  a  minimum,  and  that  the  processes  of  absorp- 
tion and  repair  be  disturbed  as  little  as  possible  and  furthered  in 
every  way.  Tranquillity  and  rest  for  the  nervous  system  are  also 
of  paramount  importance.  To  secure  proper  protection  against 
infection  for  the  lying-in  patient,  her  room  should  be  clean  and 
not  connected  with  any  channel  leading  to  decomposing  material. 
Thus,  it  is  better  that  there  be  in  her  apartment  no  pipe 
leading  to  a  cesspool,  drain  or  sewer.  Occasionally,  heating 
apparatus  may  become  a  source  of  danger,  as  illustrated  in  a  hos- 
pital where  a  nurse  had  carelessly  thrown  a  napkin,  stained  with 
the  lochial  discharge,  into  an  unused  furnace ;  a  flue  from  the 
furnace  opened  near  the  bed  of  a  patient  recently  confined,  who 
contracted  septic  infection  from  air  conveyed  through  the  flue 
from  the  furnace  below.  More  frequently,  however,  the  immediate 
environment  of  the  patient  may  become  a  source  of  safety  or  of 
danger.  Thus,  her  bed  and  bedding  should  be  absolutely  clean ; 
the  effete  material  removed  from  her  body  by  the  intestines  and 
kidneys  should  be  promptly  disposed  of,  and  the  lochial  discharge 
should  be  absorbed  in  such  a  manner  as  to  prevent  its  decom- 
position. The  air  which  the  patient  breathes  should  be  pure, 
fresh,  and  frequently  renewed.  Processes  of  excretion  and  invo- 


THE    PUERPERAL   STATE.  209 

lution  are  best  furthered  by  promoting  the  action  of  the  excre- 
tory organs,  and  by  favoring  nutrition  in  every  possible  way. 
Thus,  it  is  an  excellent  custom  to  secure  a  thorough  evacuation 
of  the  intestines  on  the  second  or  third  day  after  labor,  and  the 
bowels  should  move  at  least  once  in  two  days  through  the  lying-in 
period.  The  action  of  the  kidneys  should  be  encouraged  by 
water  freely  taken.  The  skin  should  be  stimulated  to  perform  its 
function  by  a  daily  bath,  followed  by  gentle  massage.  The  ner- 
vous system  of  the  patient  should  be  afforded  rest  by  securing 
absolute  freedom  from  intrusion. 

As  regards  the  absorption  of  the  lochia  and  the  prevention 
of  absorption  by  wounded  surfaces  of  the  genital  tract,  anti- 
septics are  indicated.  It  has  formerly  been  customary  to  re- 
ceive the  lochial  discharge  upon  napkins,  which  were  cleansed 
when  soiled,  and  used  again.  As  our  knowledge  of  antiseptics 
has  increased,  this  practice  has,  so  far  as  possible,  been  super- 
seded by  the  use  of  absorptive  dressings,  which  are  destroyed 
when  soiled.  These  dressings  have  the  further  use  of  occluding 
the  genital  canal,  and  preventing  the  entrance  of  infectious 
germs  from  the  outside.  Among  the  many  occlusion  and  ab- 
sorptive dressings  employed  may  be  mentioned  sublimated  jute 
enclosed  in  cheese-cloth  soaked  in  sublimated  solution ;  old, 
soft  linen,  antisepticized  in  the  same  manner,  and  made  into 
absorptive  pads,  and,  in  the  experience  of  the  writer,  a  pad  or 
napkin  made  as  follows :  first,  a  strip  of  picked  oakum  or  jute 
three-fourths  of  an  inch  thick,  sixteen  inches  long,  five  inches 
wide.  On  each  side  of  this,  cheap  cotton  batting,  sufficient  to 
cover  and  inclose  the  oakum.  The  whole  is  included  in  a  piece 
of  cheese-cloth,  eighteen  inches  long,  twelve  or  thirteen  wide. 
The  edges  of  the  cheese-cloth  are  brought  together  and  secured 
loosely  by  cotton  thread.  The  ends  may  be  closed  to  advantage 
in  the  same  manner.  This  napkin  is  dipped  in  bichloride  of 
mercury,  one  to  two  thousand,  and  dried. 

On  an  average,  six  or  eight  are  required  for  the  first  three  or 
four  days  after  confinement,  and  subsequently  four  daily.  When 
the  material  is  bought  in  large  quantities  at  wholesale,  and  these 

9* 


210  MANUAL    OF    PRACTICAL    OBSTETRICS. 

napkins  are  made  by  hospital  nurses,  the  material  itself,  exclusive 
of  the  labor  and  the  bichloride  of  mercury  used,  costs  one  and 
one-quarter  cents  for  each  napkin.  When  a  small  quantity 
are  made — less  than  a  hundred — the  napkins  cost,  also  exclud- 
ing labor  and  bichloride,  about  three  cents  each.  When  stained 
through,  the  pad  is  removed,  rolled  up  in  a  bit  of  old  paper, 
and  burned. 

The  question  as  to  the  possibility  of  a  patient  infecting  herself 
with  puerperal  sepsis  from  the  secretions  or  discharges  of  her  own 
body  has  occasioned  much  discussion.  If  auto-infection  be  pos- 
sible, then  the  lochial  discharge  is  extremely  dangerous  to  the 
patient,  and  should  be  thoroughly  antisepticized.  If,  on  the 
other  hand,  the  lochial  discharge  is  dangerous  only  after  it  has 
come  in  contact  with  the  external  atmosphere  and  undergone  a 
partial  decomposition,  then  the  lochial  discharge  does  not  need 
to  be  antisepticized  except  after  it  has  emerged  from  the  body 
into  the  external  atmosphere.  If  an  examination  of  the  genital 
tract  of  the  mother  be  made  after  labor  to  determine  presence  or 
absence  of  septic  bacteria  in  her  lochial  discharge,  it  is  found 
that  only  where  the  lochia  come  in  contact  with  the  atmosphere 
do  septic  germs  exist.  In  the  lower  portion  of  the  vagina  are 
found  the  lower  orders  of  bacterial  life.  The  interior  of  the 
uterus  in  a  normal  case  contains  no  septic  germs  whatever,  and 
hence  requires  no  disinfection.  The  routine  use,  then,  of  vagi- 
nal douches  after  labor  is  quite  unnecessary,  and  often  harmful, 
because  of  the  risk  of  infection  which  occurs  whenever  the  human 
body  is  entered  by  any  instrument  or  appliance.  Practically, 
then,  when  a  patient  has  not  been  infected  before  labor  by 
syphilis,  gonorrhoea,  or  septic  infection,  she  needs  after  labor 
but  a  single  vaginal  douche.  This  should  be  given  of  bi-chlor- 
ide  of  mercury  one  to  five  thousand.  After  this  no  douches  are 
needed,  but  the  parts  should  be  bathed  with  the  same  solution 
after  the  renewal  of  each  pad,  and  especially  after  the  bladder 
and  rectum  are  emptied.  It  is  well,  in  all  cases  where  specific, 
septic  or  catarrhal  inflammation  of  the  genital  tract  has  occurred 
before  labor,  to  give  the  patient  a  preliminary  douche  of  some 


THE    PUERPERAL   STATE.  211 

antiseptic  when  labor  begins.  Bi-chloride  of  mercury  one  to 
five  thousand  is  often  employed.  A  preparation  of  green  soap 
and  creolin,  so  combined  as  to  contain  from  one  to  two  per 
cent,  of  creolin,  has  been  used  in  the  Philadelphia  Hospital  for 
several  years  with  advantage.  The  soap  is  especially  efficient  in 
removing  retained  and  partly  decomposed  secretions. 

Especial  precautions  are  necessary  whenever  occasion  arises 
for  catheterizing  the  patient.  The  catheter  should  be  kept  in  a 
five  per  cent,  solution  of  carbolic  acid,  or  a  one  to  one  thousand 
solution  of  bi-chloride  of  mercury.  Before  its  introduction  the 
attendant  should  carefully  cleanse  the  orifice  of  the  meatus  with  a 
bi-chloride  solution  one  to  five  thousand.  The  catheter  should 
then  be  inserted  without  coming  in  contact  with  the  patient's 
bedding  or  surrounding  portions  of  her  body.  After  the  bladder 
has  been  emptied,  the  parts  should  again  be  cleansed  in  the  same 
way  as  before  the  insertion  of  the  catheter.  With  these  precau- 
tions it  is  possible  to  avoid  infection  of  the  bladder,  although, 
without  them,  such  infection  and  consequent  inflammation  are 
very  apt  to  occur. 


CHAPTER    XXXI. 

THE    PUERPERAL   STATE  :     LACTATION. 

THE  breasts  of  the  mother  also  require  attention  during  the 
lying-in  period  to  prevent  the  entrance  of  germs  and  the  develop- 
ment of  mammary  abscesses.  During  the  latter  months  of  preg- 
nancy the  patient  should  have  washed  the  nipples  thoroughly 
with  Castile  soap  and  warm  water,  and  if  any  cracks  or  abrasions 
exist,  an  ointment  of  boracic  acid,  ten  grains  to  the  ounce  of 
some  suitable  fat,  should  be  employed.  At  the  time  of  labor  it 
is  well  to  prevent  congestion  and  over-distension  of  the  breast, 
and  also  to  take  precautions  that  some  of  the  lower  forms  of  bac- 
teria, which  easily  infest  the  child's  mouth,  should  not  form  upon 
the  nipple.  The  breasts  may  be  advantageously  supported  and 
compressed  by  several  forms  of  breast  bandages.  Thus  a  broad 
figure  of  8  may  be  passed  around  the  breasts  and  over  the  shoul- 
ders. A  breast-binder  may  be  used  which,  in  the  experience  of 
the  writer,  has  never  occasioned  inconvenience,  and  usually 
proves  a  considerable  comfort.  This  should  be  fitted  by  the 
nurse  at  the  time  when  the  breasts  become  distended.  A  strip 
of  unbleached  muslin  or  Canton  flannel  should  be  selected,  large 
enough  to  encircle  the  body,  lapping  over  between  the  breasts, 
and  wide  enough  to  go  over  the  axillary  line  to  the  extremity 
of  the  sternum.  This  may  then  be  pinned  about  the  patient,  the 
line  of  pinning  being  in  the  centre  of  the  body  between  the 
breasts.  Opposite  to  the  nipples  two  holes  should  be  cut  the  size 
of  a  silver  quarter  of  a  dollar,  and  these  apertures  should  be 
bound  with  strong  tape,  otherwise  the  weight  of  the  breast  will 
force  the  gland  through  the  bandage,  tearing  it  asunder.  An 
aperture  of  this  size  will  ordinarily  enable  an  infant  to  nurse 
without  removing  the  bandage,  but  should  it  be  desired  to  en- 

212 


THE    PUERPERAL   STATE:    LACTATION.  213 

large  the  aperture,  this  may  be  done  to  any  extent  required. 
Shoulder-straps  are  then  fitted,  being  fastened  anteriorly  to  the 
upper  edge  of  the  bandage,  passing  over  the  shoulder  to  the 
upper  edge  of  the  bandage  upon  the  other  side  and  behind.  By 
tightening  or  loosening  the  shoulder-straps  the  breasts  may  be 
gathered  toward  the  median  line,  and  raised  toward  the  upper 
portion  of  the  body.  In  this  way  the  patient  will  experience  a 
marked  degree  of  comfort,  and  over-distension  and  threatened 
engorgement  may  be  prevented.  Infection  of  the  nipple  and 
of  the  breasts  may  be  guarded  against  by  cleansing  the  nipple 
thoroughly  after  each  nursing  with  a  saturated  solution  of  boracic 
acid,  to  which  a  little  glycerine  has  been  added.  Should  cracks 
or  fissures  occur,  they  may  be  painted,  after  being  cleansed,  with 
compound  tincture  of  benzoin. 

It  will  be  found  advantageous  to  take  precautions  to  avoid  the 
growth  of  bacteria  in  the  mouth  of  the  child.  While  septic 
bacteria  do  not  often  gain  access  to  the  child's  mouth,  yet  some 
of  the  lower  forms  of  these  germs  are  very  commonly  found 
there,  and  may  infect  the  mother's  nipple.  It  is  well  to  cleanse 
the  child's  mouth,  after  nursing,  with  a  bit  of  soft  old  linen, 
dipped  in  a  saturated  solution  of  boracic  acid,  to  which  a  little 
glycerine  has  been  added.  The  breasts  should  be  nursed,  so  far 
as  possible,  in  alternation.  During  the  day,  two  hours  is  a 
convenient  interval  for  the  child  to  nurse,  and  during  the  night, 
twice  between  ten  in  the  evening  and  six  in  the  morning  is 
quite  sufficient.  If  the  nurse  insists  upon  the  child's  feeding 
regularly  through  the  day,  even  waking  it  if  necessary,  it  will 
be  much  more  likely  to  sleep  at  night,  and  will  be  well  able 
to  do  with  less  frequent  nursing.  No  absolute  rule  can  be 
laid  down  regarding  the  amount  which  any  child  should  take. 
The  child's  appetite,  if  it  be  properly  taken  care  of,  is  usually 
the  best  guide.  When  a  child  nurses  with  great  greediness, 
some  abnormality  in  digestion  should  be  suspected,  and  sought 
for,  if  possible.  Such  children  are  very  apt  to  regurgitate  very 
frequently  after  nursing,  and  are  often  troubled  with  indigestion 
and  flatulence.  The  habit  of  greedy  nursing  may  sometimes  be 


214  MANUAL   OF    PRACTICAL   OBSTETRICS. 

corrected  if  the  mother  will  allow  the  nipple  to  rest  between 
two  fingers  of  the  hand  which  is  supporting  the  breast.  Pressure 
upon  the  nipple  in  this  manner  will  regulate  the  flow  of  milk, 
and  prevent  too  large  an  amount  from  entering  the  child's 
stomach  at  once.  On  the  other  hand,  a  tardy  secretion  of  milk 
may  occasion  some  anxiety  for  fear  lest  the  infant  suffer.  If  the 
usual  preliminary  flow  of  colostrum  is  present,  but  little  uneasiness 
should  be  felt,  although  the  discharge  from  the  breast  remains  thin. 
If  the  infant  cries  from  hunger  which  cannot  be  appeased,  one  or 
two  meals  of  sterilized  milk  may  be  given  during  the  twenty  four 
hours. 

It  not  infrequently  happens  that  some  abnormal  condition 
of  the  mother's  milk  exists,  which  causes  it  to  disagree  with  the 
infant.  A  gross  inspection  of  such  milk  would  result  in  finding 
it  thinner  than  normal,  and  bearing  the  appearances  of  a  fluid 
deficient  in  the  amount  of  fat.  An  accurate  idea  of  the  compo- 
sition of  such  milk  can  only  be  obtained  by  subjecting  it  to  an 
examination  with  a  lactometer,  and  also  to  microscopic  examina- 
tion. As  the  physician  cannot  always  have  a  lactometer  at  his 
disposal,  he  will  do  well  to  rely  largely  upon  his  microscope. 
Normal  milk,  when  viewed  under  the  microscope,  presents  a 
number  of  rounded  bodies  which  are  the  milk  globules.  They 
are  of  fairly  uniform  size,  and  are  smooth  and  not  granular  in 
appearance.  In  the  first  milk  or  colostrum  which  forms,  there  are 
found  numerous  young  epithelial  cells,  which  are  derived  from 
the  gland  tubules  of  the  breast.  As  the  secretion  of  milk  becomes 
established,  these  colostrum  corpuscles,  as  they  are  often  called, 
disappear,  and  in  their  place  the  field  of  the  microscope  is  found 
to  contain  the  rounded,  smooth,  corpuscular  body  which  forms 
the  essential  element  in  milk.  The  fully  developed  milk-globule 
is  a  cell  composed  of  an  albuminoid  outer  wall  or  envelope,  con- 
taining a  small  amount  of  fat.  When  digestion  occurs,  the 
albuminoid  envelope  is  digested  and  dissolved,  and  the  fat  is 
directly  absorbed  in  the  lacteals.  If  a  microscopic  examination 
be  made  of  the  stomach  of  an  animal  digesting  milk,  the  fat  of 
the  milk  may  be  observed  in  a  state  of  granular  degeneration 


THE    PUERPERAL   STATE:    LACTATION.  215 

in  the  tubules  of  the  stomach  and  intestines.  It  is  then  under- 
going the  process  of  absorption.  If  the  physician,  upon 
examining  a  sample  of  milk,  finds  many  colostrum  corpuscles 
present,  and  that  the  number  of  milk-globules  is  deficient ;  that 
they  are  not  of  a  fairly  uniform  size,  and  seem  not  to  be  present 
in  abundance  in  the  field,  he  may  reasonably  infer  that  the  milk 
is  deficient  in  quality.  If,  furthermore,  he  should  observe  blood- 
corpuscles,  pus-cells  and  bacteria  in  the  milk,  he  should  at  once 
reject  it  for  use,  as  being  infected  with  some  form  of  puerperal 
infection.  Should  the  mother  be  suffering  from  tuberculosis  of 
the  breast,  the  tubercle  bacilli  can  be  detected  in  the  milk. 

Much  discussion  has  been  aroused  regarding  the  influence  of 
the  mother's  diet  upon  the  secretion  and  quality  of  her  milk.  It 
has  been  a  common  practice  to  interdict  such  articles  of  food  as 
are  supposed  to  "sour"  the  milk.  Such,  for  example,  are  acids 
and  food  cooked  or  dressed  with  an  acid.  Salad  and  pickles  were 
considered  as  highly  objectionable  food  for  a  nursing  mother. 
Further  studies  on  the  mother's  digestion  have  shown  that  what- 
ever agrees  with  her  personally,  and  whatever  is  digested  well,  as 
a  rule  produces  milk  for  her  child.  The  food  of  the  nursing 
mother  should  be  easily  digested,  abundant  in  quantity,  palatable, 
and,  if  possible,  enjoyable.  Certain  articles  of  food  tend  to 
increase  materially  the  flow  of  milk ;  such  are  milk  itself,  when 
taken  freely  by  the  mother ;  beets,  vegetables  containing  sugar ; 
chocolate  and  cocoa  are  beverages  tending  to  increase  the  secre- 
tion of  milk.  Beer  and  porter,  in  many  cases,  and  water,  are 
also  beverages  of  practical  value. 

Patients  differ  greatly  in  regard  to  the  perfect  performance  of 
the  function  of  lactation.  Drugs  given  to  promote  the  secretion 
and  flow  of  milk  are  useful  only  as  they  are  general  tonics. 
There  is  no  specific  of  practical  and  continued  value  in  these 
cases.  The  care  of  the  breasts  during  the  period  when  lactation 
is  about  to  be  established  is  a  matter  of  considerable  importance. 
Not  only  should  the  nipple  be  kept  thoroughly  cleansed,  as  has 
been  described,  but  the  settling  and  accumulation  of  milk  in  any 
portion  of  the  breast  should  be  prevented  by  gentle  friction  and 


21 6  .MANUAL   OF   PRACTICAL   OBSTETRICS. 

massage  over  those  portions  of  the  gland  where  the  milk-ducts 
are  distended  and  hardened.  More  important,  however,  is  the 
use  of  the  bandage  as  has  been  described. 

Certain  drugs  are  excreted  very  rapidly  through  the  mother's 
milk.  Such  are  potassium  iodide,  the  iodides,  chlorides  and 
certain  drugs  affecting  the  central  nervous  system  profoundly. 
It  has  been  supposed  that  opium,  when  taken  by  the  mother, 
passed  soon  into  the  milk,  and  thence  to  the  child.  While 
this  is  undoubtedly  partially  true,  yet  there  is  reason  to  be- 
lieve that  it  passes  less  readily  into  the  milk  than  has  been  sup- 
posed. Quinine,  when  given  to  the  mother,  affects  the  child 
through  the  milk,  and  many  purgative  medicines  have  the  same 
effect. 


CHAPTER  XXXII. 

ARTIFICIAL   FEEDING   OF   INFANTS. 

IT  not  infrequently  happens  that  the  function  oflactation  fails; 
this  may  arise  from  deficient  vigor  on  the  part  of  the  mother  without 
any  one  local  or  specific  disease.  It  also  follows  the  acute  infec- 
tions of  whatever  sort,  of  which  septic  infection  is  the  most  familiar 
example.  Malformation  of  the  breasts  and  occlusion  of  the  ducts 
of  the  nipple  are  also  causes.  A  sudden  and  severe  shock  to  the 
nervous  system  of  the  mother  may  produce  cessation  of  lactation. 
This  function  may  be  artificially  suspended  in  cases  where  the 
child  is  still-born,  or  where  it  is  necessary  to  separate  mother  and 
child  immediately  after  birth.  There  are,  again,  certain  causes 
which  contra-indicate  lactation,  although  the  function  may  be- 
come established ;  such  are,  a  manifest  lack  of  strength  on  the 
part  of  the  mother,  even  although  no  well-defined  disease  be 
present ;  thus,  a  woman  may  have  been  observed  to  fail  in  health 
while  nursing  a  child,  this  failure  being  more  pronounced  after 
each  successive  pregnancy;  a  woman  suffering  from  tuberculosis, 
syphilis,  cancer,  or  any  other  pronounced  infection,  should  not 
nurse  her  infant.  A  curious  exception  to  this  rule  is  sometimes 
observed  in  women  suffering  from  scarlatina;  cases  are  on  record 
where  such  patients  have  nursed  their  infants  without  injury  to 
the  latter.  It  is  sometimes  necessary  to  suspend  nursing  in  the 
interest  of  the  mother  because  of  its  exhausting  effect  upon  her. 

In  the  interest  of  the  child,  again,  it  may  be  necessary  to  supple- 
ment mother's  milk  by  some  artificial  food,  or  to  suspend  lacta- 
tion entirely,  or  to  feed  the  child  wholly  upon  some  source  of 
nutrition  other  than  the  mother's  milk.  In  the  interest  of  the 
child  when  its  mother  cannot  nourish  it,  a  substitute  or  wet-nurse 
is  most  desirable.  The  selection  of  a  wet-nurse  should  always 
10  217 


21 8  MANUAL   OF    PRACTICAL    OBSTETRICS. 

devolve  upon  the  physician,  and  is  to  be  made  in  the  most 
careful  manner ;  such  a  woman  should  be  as  nearly  as  possible  of 
the  same  age  as  the  mother,  and  her  infant  should  also  corre- 
spond in  age  to  the  one  which  she  intends  to  feed.  The  physi- 
cian will  carefully  examine  the  proposed  wet-nurse  for  any 
evidence  of  syphilis,  tuberculosis,  or  septic  infection.  The  con- 
dition of  her  digestive  organs  must  also  be  ascertained,  as  well 
as  any  taint  from  alcoholism  or  other  objectionable  habit. 
Women  of  a  placid  disposition,  good  constitution  and  simple, 
regular  habits,  are  best  fitted  for  this  duty.  There  can  be  no 
objection  to  examining  the  milk  of  such  a  woman  microscopi- 
cally and  chemically,  but  a  convenient  practical  test  is  found  in 
the  condition  of  her  own  child ;  if  that  is  healthy  and  well  nour- 
ished, it  is  but  reasonable  to  expect  that  another  child  fed  by 
her  should  be  in  similar  condition.  The  breasts  should  also  be 
examined  to  see  that  they  are  well  formed,  and  that  the  nipples 
are  not  sore  nor  likely  to  become  so.  A  not  uncommon  mistake 
in  the  treatment  of  wet-nurses  is  the  radical  change  in  their 
habits  and  style  of  living  which  is  brought  about  by  the  zealous 
but  unwise  anxiety  of  parents  to  feed  them  well;  women  accus- 
tomed to  frugal  habits  of  living,  active  work  and  long  hours  of 
sleep,  if  confined  to  a  house,  fed  upon  rich  and  indigestible  food, 
and  disturbed  at  night  to  nurse  too  frequently  a  fretful  child, 
cannot  remain  long  in  good  health,  nor  will  their  milk  afford 
proper  nourishment  for  an  infant.  Care  should  also  be  taken 
that  the  wet-nurse  be  subjected  to  as  few  mental  and  nervous  dis- 
turbances as  possible.  Since  a  better  knowledge  of  infant  feed- 
ing is  beginning  to  prevail,  the  employment  of  wet-nurses  is  not 
so  general  as  formerly.  Physicians  appreciate  that  it  is  no  incon- 
siderable risk  to  take  a  stranger  from  a  hospital  to  serve  as  wet- 
nurse,  and  many  prefer  to  prepare  foods  in  a  well-known  and 
accurate  manner  rather  than  to  trust  to  nourishment  derived  from 
a  woman  of  comparatively  unknown  antecedents. 

The  most  natural  substitute  for  mother's  milk  is  that  of  the 
cow;  while  it  occasionally  happens  that  nothing  but  goat's  milk 
will  agree  with  the  child,  yet  in  the  majority  of  cases  cow's  milk 


ARTIFICIAL   FEEDING   OF   INFANTS.  219 

may  be  so  modified  as  to  fulfill  the  indications.  It  is  essen- 
tial that  this  milk  be  produced  under  circumstances  favorable 
to  its  purity,  and  be  conveyed  to  the  consumer  as  promptly  as 
possible,  and  in  as  pure  a  condition  as  possible.  Observation 
has  shown  that  finely  bred  cattle  are  often  subject  to  tubercular 
disease,  and  that  tubercular  infection  can  be  conveyed  to  an  in- 
fant through  cow's  milk;  hence  the  average  cow  of  fair  breed  is 
preferred  rather  than  the  highly  bred  animal;  it  is  sometimes 
observed  that  the  milk  of  one  cow  agrees  better  with  an  infant 
than  the  milk  of  another  cow  of  the  same  kind,  and  living  under 
the  same  circumstances. 

By  sterilization  of  milk  we  understand  such  a  process  as  shall 
destroy  noxious  bacteria  and  thus  render  milk  a  safe  food.  Nu- 
merous researches  have  been  made  in  this  matter,  but  experience 
points  at  the  present  time  to  the  following  as  the  best  method  of 
preparation :  Milk  should  be  allowed  to  stand  for  a  little  time 
in  order  that  any  impurities  which  will  gravitate  to  the  bottom 
may  have  an  opportunity  to  settle;  there  is  no  objection,  fur- 
ther, to  skimming  the  milk  lightly,  not  removing,  however,  the 
greater  portion  of  the  cream.  Milk  should  be  sterilized,  if  pos- 
sible, in  the  bottle  from  which  the  child  will  nurse,  and  a  suffi- 
cient number  of  bottles  should  be  provided  so  that  sterilization 
may  be  conveniently  performed  once  in  twenty-four  hours;  the 
milk  should  first  be  rendered  slightly  alkaline  in  reaction,  by  the 
addition  of  lime-water  in  the  proportions  of  half  ounce  for  an 
eight  ounce  mixture;  it  should  then  be  poured  into  the  bottle,  a 
funnel  having  been  used  so  that  the  neck  of  the  bottle  does  not 
become  wet.  In  each  eight  ounces  for  a  new-born  child  the 
proportions  may  be  as  follows:  Cream,  ounces,  i^;  milk, 
ounces,  i ;  lime-water,  ounces,  ^  ;  sugar  of  milk,  i  teaspoonful ; 
water  to  make  8  ounces ;  the  bottle  should  then  be  corked  with 
cotton-wool  or  cotton  batting,  which  has  been  previously  baked 
in  the  oven  until  it  is  brown;  the  bottle  should  then  be  placed 
in  a  pan  containing  about  three  inches  of  water  and  placed  upon 
the  fire,  and  allowed  to  heat  to  a  temperature  of  155  F.  for  six 
minutes.  If  the  milk  must  be  kept  longer  than  twenty-four 


220  MANUAL   OF   PRACTICAL    OBSTETRICS. 

hours  it  should  be  allowed  to  come  to  the  boiling  point  for  one 
or  two  minutes ;  the  bottles  should  then  be  removed  from  the 
fire  and  allowed  to  cool,  and  kept  upon  ice  or  in  a  cool  place 
until  they  are  required.  When  it  is  time  for  the  child  to  nurse, 
the  bottle  should  be  placed  in  a  basin  containing  a  few  inches 
of  water,  put  upon  the  fire  and  warmed  to  a  blood  heat,  98°  F. ; 
the  cotton  cork  is  then  removed  and  a  plain  black  rubber  nipple, 
which  has  been  previously  cleansed  in  a  saturated  solution  of  bora- 
cic  acid,  should  be  placed  upon  the  bottle  and  the  child  allowed 
to  nurse.  It  will  be  noticed  that  this  formula  calls  for  a  very 
dilute  mixture,  adapted  for  a  new-born  infant;  as  the  child  grows 
older  the  amount  of  water  in  the  mixture  is  decreased,  the  relative 
amount  of  milk  and  cream  remaining  the  same,  while  both  are  in- 
creased. In  regard  to  the  amount  to  be  given  to  the  child  at  each 
feeding,  each  infant  is  a  law  unto  himself;  the  common  mistake 
is  in  over-feeding,  and  hence  it  is  better  to  begin  with  three 
ounces  every  two  or  three  hours  during  the  day,  four  ounces 
taken  twice  during  the  night.  The  bottle  ought  not  to  be  given 
to  the  child  and  left  without  supervision  to  nurse,  but  its  nursing 
should  be  watched,  and  then  an  intelligent  idea  of  its  appetite 
and  needs  can  be  obtained.  The  child  should  not  be  allowed 
to  lie  with  the  bottle  "beside  it,  the  nipple  in  its  mouth;  it 
should  feed  until  it  is  done,  and  then  the  bottle  should  be  taken 
away. 

Digestive  ferments  are  often  employed  to  advantage  with 
infants.  Milk  may  be  peptonized,  then  sterilized,  as  has  been 
described,  or  pepsin  and  pancreatin  may  be  given  just  before 
feeding;  cod  liver  oil  is  a  most  useful  aid  in  promoting  infant's 
nutrition,  and  olive  oil  will  be  often  taken  with  avidity  and 
benefit. 

It  is  quite  evident  that  precautions  taken  to  secure  cleanliness 
in  dairies  are  more  important  than  any  method  of  preparing 
milk  subsequently ;  hence  the  milch  cows  should  be  kept  per- 
fectly clean,  the  hide  curried  as  carefully  as  that  of  a  horse, 
the  floor  of  the  stable  kept  as  clean  as  possible,  and  before 
milking  care  taken  that  the  udder  and  teats  of  the  animal  and 


ARTIFICIAL    FEEDING   OF   INFANTS.  221 

the  hands  of  the  milker  should  also  be  clean.  It  is  sometimes 
well  to  milk  directly  into  glass  jars  which  have  been  previously 
scalded,  and  which  may  be  sealed  hermetically  until  received 
by  the  consumer;  before  shipment  milk  should  be  kept  in  a 
clean,  cool  place,  especially  free  from  the  presence  of  rotting 
vegetable  or  animal  matter,  as  it  has  been  shown  that  poisonous 
elements  may  be  developed  in  milk  in  unfavorable  surround- 
ings. It  will  sometimes  be  observed  that  obstinate  constipa- 
tion in  infants  follows  the  use  of  sterilized,  scalded  or  boiled 
milk;  this  results  from  a  change  in  the  albuminoid  bodies  in  the 
milk,  and  can  usually  be  counteracted  by  diluting  the  milk  with 
oatmeal  water,  instead  of  the  water  otherwise  employed ;  while 
if  diarrhoea  is  present  with  acute  dyspepsia,  barley-water  may  be 
substituted  for  oatmeal-water  ;  it  is  well  to  avoid  the  use  of  cane 
sugar,  as  fermentation  happens  more  readily  in  mixtures  contain- 
ing cane  than  in  those  sweetened  with  milk  sugar ;  in  using  milk 
sugar  care  should  be  taken  that  it  is  of  the  best  quality,  as  it 
sometimes,  when  impure,  causes  indigestion.  When  a  sudden 
attack  of  acute  enteritis  comes  on,  there  is  no  question  of  the 
wisdom  of  stopping  milk  at  once;  the  child  can  be  well  supported 
by  whiskey  and  water,  or  brandy  and  water,  and  by  the  white 
of  a  raw  egg  mixed  with  water  and  slightly  sweetered;  by  care- 
fully made  chicken  or  mutton  broths,  or  by  arrow  root  or  barley 
gruels.  As  infancy  advances,  it  will  be  found  advantageous  to 
combine  with  cow's  milk  some  of  the  prepared  foods  offered  in 
market ;  the  essential  constituents  of  these  foods  is  usually  dias- 
tase or  starch,  or  some  albuminoid  derived  from  grain.  With 
healthy  children  in  the  country,  bread  and  milk,  mashed  pota- 
toes carefully  prepared,  broths,  soups  and  soft-boiled  eggs  usually 
furnish  a  proper  transition  from  a  diet  of  milk  to  the  mixed  diet 
of  childhood. 


CHAPTER  XXXIII. 

ABNORMAL   INSERTION  OF  THE   PLACENTA,  PLACENTA  PR/EVIA. 

THE  usual  location  of  the  placenta  is  upon  the  anterior  or  poste- 
rior uterine  wall,  above  the  level  of  the  lower  uterine  segment ; 
in  multipart,  especially  those  who  have  suffered  from  endometri- 
tis,  atrophy  of  the  villous  tissue  in  the  placental  decidua,  and 
placental  development  in  the  decidua  reflexa,  result  in  failure  of 
the  placenta  to  adhere  to  its  customary  location.  In  the  upper 
two-thirds  of  the  uterus  the  distended  and  relaxed  condition 
commonly  found  in  multiparse  also  favors  the  location  of  the 
placenta  in  the  lower  uterine  segment  or  cervix. 

Placenta  Praevia  may  be  of  four  varieties :  central  (placenta 
praevia  centralis),  partial  (placenta  praevia  partialis),  marginal 
(placenta  prasvia  marginalis),  lateral  (placenta  praevia  lateralis). 
The  first  and  most  dangerous  form  is  that  in  which  the  placenta 
is  directly  o-.ci  the  mouth  of  the  uterus,  between  the  child  and 
the  external  world ;  a  diagnosis  of  this  condition  is  made  by  the 
haemorrhage  which  is  inevitable  so  soon  as  dilatation  of  the  os 
begins.  Upon  examination,  instead  of  finding  the  membranes, 
the  examiner  comes  upon  a  fleshy  mass  which  is  easily  distin- 
guished as  the  placenta;  bleeding  in  these  cases  is  severe, 
often  fatal.  It  is  impossible  for  the  physician  to  find  any  portion 
of  the  mouth  of  the  womb  not  filled  up  by  the  placenta. 

In  partial  placenta  praevia,  when  a  portion  of  the  mouth  of 
the  womb  is  covered  by  the  placenta,  there  can  be  distinguished 
at  one  side  a  vacant  space  where  the  membranes  may  be  felt. 

In  marginal  placenta  praevia,  the  mouth  of  the  womb  is  entirely 
free  from  the  placenta,  but  by  feeling  around  the  margin  of  the 
os  uteri  the  finger  detects  the  placenta  upon  one  side,  just  at  the 
edge  of  the  lumen  of  the  os. 

222 


Plate  XI. 


Davis'  Obstetrics. 


Position  of  Placenta  over  os  uteri,  from  body  of  a  woman  who 
died  of  Uterine  Haemorrhage  in  the  ninth  month  of  preg- 
nancy. Placenta  praevia  centralis.  (Martin.) 


ABNORMAL   INSERTION   OF   THE    PLACENTA.  223 

In  lateral  placenta  praevia  the  placenta  is  attached  to  the  lower 
uterine  segment  above  the  os,  and  often  cannot  be  found  by 
examination.  Its  situation  must  be  inferred  from  the  haemor- 
rhage which  occurs  when  dilatation  advances,  and  the  lower 
uterine  segment  is  distended. 

In  general  terms  it  may  be  stated  that  placenta  praevia  is  that 
location  of  the  placenta  from  which  it  is  detached  from  the  uterus 
during  the  stage  of  dilatation.  The  important  symptom  of  pla- 
centa praevia  is  haemorrhage  occurring  suddenly  without  recognized 
cause,  often  following  the  assumption  of  the  erect  posture ;  it  is 
usually  not  difficult  to  confirm  a  diagnosis  by  examination. 

The  dangers  of  placenta  praevia  to  the  mother  arise  from 
haemorrhage  and  shock,  and  collapse  following,  and  also  from 
septic  infection;  the  dangers  to  the  child  are  caused  by  asphyxia 
following  the  premature  detachment  of  the  placenta  and  the  cut- 
ting off  of  the  supply  of  maternal  blood. 

The  treatment  of  placenta  praevia  consists,  in  the  interest  of 
the  mother,  in  preventing  haemorrhage  and  septic  infection, 
in  the  interest  of  the  child,  in  securing  delivery  as  promptly  as 
possible.  Haemorrhage  can  usually  be  controlled  until  dilatation 
is  sufficiently  advanced  to  secure  delivery  by  the  use  of  the  anti- 
septic tampon .  lodoform  gauze  is  the  best  material  for  this  pur- 
pose, and  may  be  cut  into  strips  three  inches  wide  and  three  or 
four  feet  long ;  such  a  tampon  should  be  used  in  cases  where  the 
haemorrhage  is  not  severe  and  sudden,  and  where  dilatation  is  so 
little  advanced  that  combined  version  or  internal  version  cannot 
be  employed.  The  end  of  the  strip  of  gauze  should  be  inserted 
within  the  os  and  cervix  against  the  placenta,  and  the  parts 
should  be  thoroughly  distended  by  the  tampon.  The  vagina 
should  also  be  moderately  distended  and  uterine  contraction 
stimulated  if  necessary  by  gentle  friction  or  administration  of 
small  doses  of  ergot.  When,  however,  central  placenta  praevia 
exists,  the  physician  should  be  prepared,  as  soon  as  he  can  intro- 
duce several  fingers  or  his  hand  into  the  uterus,  to  force  his  hand 
through  the  placenta;  seize  a  foot  and  bring  down  the  breech  of 
the  child  to  act  as  a  tampon  (Fig.  107). 


224 


MANUAL    OF    PRACTICAL    OBSTETRICS. 


In  partial,  marginal  and  lateral  placenta  praevia,  if  the  head 
presents,  and  uterine  contraction  is  good,  it  is  often  sufficient  to 
rupture  the  membranes,  when  the  head  will  compress  the  pla- 
centa between  it  and  the  side  of  the  pelvis,  thereby  stopping 
haemorrhage;  in  cases  where  dilatation  proceeds  slowly,  a  Barnes' 

FIG.  107. 


PLACENTA  PR^VIA  CENTRALIS,  INTRODUCING  THE  HAND  TO  BRING 
DOWN  THE  FEET. 

dilator  can  be  used  to  secure  delivery ;  haemorrhage  can  also  be 
checked  by  bringing  down  the  fcetus  by  combined  version  to  act 
as  a  tampon;  for  this  purpose  it  is  well  to  place  the  patient 
across  a  bed,  and,  under  partial  anaesthesia,  with  careful  antisep- 
tic precautions,  to  introduce  two  or  three  fingers  of  the  hand 


ABNORMAL    INSERTION    OF   THE   PLACENTA. 


225 


which  is  opposite  the  feet  of  the  child,  pressing  the  head  and 
shoulders  up,  while  the  other  hand  pushes  the  breech  down  by 
external  pressure ;  an  anaesthetic  is  of  the  greatest  service  in  se- 
curing sufficient  relaxation  of  the  uterus  and  abdominal  muscles 
to  permit  of  this  manipulation;  afoot  is  then  seized  and  the 


FIG.  108. 


COMBINED  VERSION,  PUSHING  UP  THE  HEAD. 

breech  drawn  down  acting  as  a  tampon.  In  the  less  dangerous 
forms  of  placenta  praevia,  when  the  head  is  presenting  and  dilata- 
tion is  almost  complete,  it  is  often  possible  to  rupture  the  mem- 
branes and  apply  forceps  in  the  interests  of  both  mother  and 
child  (Figs.  108  and  109). 

After  delivery  in  cases  of  placenta  praevia,  the  uterus  should 
be  thoroughly  explored  to  be  sure  that  no  fragments  of  placenta 


226 


MANUAL   OF    PRACTICAL   OBSTETRICS. 


remain.  A  hot  intra  uterine  douche  of  half  a  gallon  of  solution 
of  carbolic  acid,  2  per  cent.,  thymol  i  to  1000,  or  creolin  ^ 
per  cent.,  should  be  given,  followed  by  the  introduction  into  the 
uterus  of  a  suppository  containing  60  grains  of  iodoform. 

The  profound  anaemia  which  accompanies  placenta  prsevia 
requires  active  and  persistent  stimulation.  Hypodermic  injec- 
tions of  ether,  digitalis, 
strophanthus,  strychnia 
and  whiskey  or  brandy 
are  familiar  agents  of 
proven  value ;  if  the  pa- 
tient is  especially  nerv- 
ous and  restless,  mor- 
phine and  atropine  will 
often  be  of  value ;  rec- 
tal injections  of  whis- 
key and  milk,  two 
ounces  of  each,  will  be 
found  very  useful;  in 
extreme  cases  some  me- 
thod of  transfusion  is 
often  of  great  value. 
Transfusion  is  of  two 
kinds :  One  in  which 
fluids  are  brought  into 
the  circulation  from 
without ;  the  other  me- 
thod is  that  by  which 

the  blood  of  the  patient  is  retained  so  far  as  possible  in  the  circula- 
tion of  the  brain  and  spinal  cord  ;  in  the  first,  while  defibrinated 
blood  has  been  found  of  great  value,  the  difficulty  of  procuring  it 
and  the  time  and  apparatus  required  render  it  inconvenient.  A 
dilute  solution  of  salines  containing  six-tenths  of  one  per  cent,  of 
sodium  salts  forms  a  useful  and  easily  procured  fluid  for  transfu- 
sion ;  sodium  chloride  and  sodium  bicarbonate  are  the  best  sub- 
stances available  for  this  fluid ;  if  possible,  water  which  has  been 


COMBINED  VERSION,  BRINGING  DOWN  THE  LEGS. 


ABNORMAL    INSERTION    OF   THE    PLACENTA.  227 

boiled  and  filtered  should  be  employed,  or  distilled  water.  In 
the  absence  of  any  means  for  making  an  accurately  measured 
fluid,  it  is  sufficient  to  add  to  water  two  parts  of  salt  and  one  of 
sodium  bicarbonate,  until  the  water  tastes  slightly  saline;  it 
should  then  be  heated  to  a  temperature  of  100°  F.,  and  introduced 
into  the  body  of  the  patient  through  a  thoroughly  cleaned  tube 
and  needle;  this  is  best  accomplished  by  gravity.  A  rubber 
tube  being  attached  to  the  needle  and  terminating  in  a  small 
funnel,  the  needle  should  be  introduced  for  a  quarter  or  half 
inch  obliquely  in  the  connective  tissue  above  the  clavicles,  in 
the  abdominal  wall  or  in  the  axillary  spaces. 

As  much  fluid  as  will  be  taken  up  by  the  tissues  may  be  intro- 
duced, the  funnel  being  constantly  full  to  prevent  the  entrance 
of  air ;  several  ounces  of  fluid  can  usually  be  inserted  at  each 
puncture,  the  tissue  around  the  seat  of  puncture  being  rubbed 
gently  to  further  the  passage  of  the  fluid  into  the  connective  tis- 
sue spaces. 

Auto-transfusion  consists  in  bandaging  the  patient's  limbs 
from  the  lower  extremities  towards  the  trunk  and  in  raising  her 
feet  sufficiently  high  to  favor  the  retention  of  blood  in  the  brain 
and  spinal  cord.  She  may  keep  on  these  bandages  and  in  this 
position  for  a  number  of  hours,  until  sufficient  stimulants  and 
fluid  can  be  given  to  maintain  the  action  of  the  heart,  when  the 
circulation  is  allowed  to  go  on  at  its  usual  rate  in  its  periphery ; 
where  respiratory  failure  threatens,  inhalation  of  oxygen  has 
proven  of  decided  benefit. 

It  is  of  the  greatest  importance  that  not  only  should  the 
mother  be  skillfully  treated  to  prevent  haemorrhage,  with  its  re- 
sults, but  that  the  most  careful  antiseptic  precautions  should  be 
taken  during  her  labor;  special  attention  should  be  given  to 
cleanliness  in  her  bedding,  and  as  regards  the  hands  and  instru- 
ments of  those  who  care  for  her. 


CHAPTER    XXXIV. 

EXTRA-UTERINE   OR   ECTOPIC   PREGNANCY. 

WHILE  the  usual  location  of  the  ovum  is  within  the  uterine 
cavity,  yet  in  probably  as  many  as  one  case  in  one  hundred  it 
lodges  and  develops  outside  the  cavity  of  the  uterus.  The  cause 
of  this  unusual  location  of  the  ovum  is  some  disease  of  the  oviduct 
which  prevents  the  passage  of  the  ovum  from  the  ovary  to  its  usual 
location  in  the  uterus;  it  is  often  the  case  that  women  who  have 
borne  children  are  more  liable  to  this  accident  than  those  who 
have  not. 

Symptoms  of  extra-uterine  pregnancy  are  usually  those  of  normal 
intra-uterine  pregnancy;  the  uterus  becomes  slightly  enlarged,  a 
deciduous  membrane  forms  within  its  cavity,  there  is  often  a  cessa- 
tion of  menstruation,  and  the  usual  subjective  symptoms  of  early 
pregnancy  are  present.  The  most  usual  location  of  the  ovum  out- 
side the  uterus  is  in  one  of  the  oviducts ;  it  occasionally  lodges  in 
that  portion  of  the  uterine  wall  where  the  oviduct  passes  into  the 
uterus,  and  ra'rely  it  remains  at  the  outer  surface  of  the  ovary  itself; 
it  is  asserted  by  some  and  denied  by  others  that  the  ovum  occa- 
sionally lodges  in  the  abdominal  cavity.  So  long  as  the  ovum 
does  not  become  too  large  for  the  oviduct,  its  presence  may  give 
rise  to  no  condition  which  can  be  detected  by  examination ;  the 
patient  presents  symptoms  of  early  pregnancy,  and,  if  kept  under 
close  observation,  the  physician  may  notice  that  the  uterus  does 
not  enlarge  progressively  as  would  be  the  case  in  normal  pregnancy 
(Fig.  no). 

In  tubal  pregnancy,  however,  the  ovum  soon  becomes  too  large 

for  the  oviduct,  and  although  the  latter  is  capable  of  considerable 

distension  and  its  muscular  tissue  may  hypertrophy  to  a  very  great 

extent,  yet,  at  about  the  third  or  fourth  month,  the  ovum  bursts  the 

228 


EXTRA-UTERINE   OR   ECTOPIC   PREGNANCY.  229 

oviduct,  and  either  remains  adherent  to  the  ruptured  tube  or  else 
escapes  between  the  folds  of  the  broad  ligament  or  into  the  ab- 
dominal cavity;  the  symptoms  of  such  rupture  are  pain,  sudden, 
sharp,  severe  in  character  and  the  discharge  of  deciduous  mem- 
brane and  blood  from  the  uterus ;  before  rupture,  at  about  the 
third  or  fourth  month,  a  tumor  as  large  as  a  small  orange  may 
possibly  be  felt  at  one  side  of  the  uterus;  after  rupture,  this  may 
be  unrecognizable  or  still  be  indistinctly  outlined ;  after  rupture 
the  ovum  may  drop  into  such  a  position  between  the  folds  of  the 
broad  ligament  that  the  clot  of  blood  which  is  poured  from  its 
sac  at  the  moment  of  rupture  is  limited  by  the  surrounding  serous 
membrane,  forming  an  haematocele ;  should  the  ovum  rupture  into 
the  abdominal  cavity,  haemorrhage  may  persist  and  become  fatal. 

FIG.  no. 


TUBAL  PREGNANCY. 


In  the  former  instance  the  symptoms  of  shock  which  accompany 
rupture  gradually  grow  less  and  the  patient  may  rally  without  treat- 
ment, except  rest  in  the  recumbent  position;  after  rupture  into  the 
abdominal  cavity  shock  persists,  a  condition  of  coma  ensues,  and 
the  patient  perishes  from  the  effects  of  haemorrhage.  Where  the 
ovum  escapes  into  the  abdominal  cavity,  it  occasionally  becomes 
encysted,  the  placenta  is  developed  from  the  mesentery  or  from  the 
intestines,  and  pregnancy  continues  to  full  term  or  even  longer;  a 
living  child  has  been  delivered  after  such  pregnancy;  when  preg- 
nancy persists  and  the  foetus  perishes,  it  usually  becomes  mummified 


230  MANUAL   OF   PRACTICAL    OBSTETRICS. 

or  macerated,  and  occasionally  calcareous  deposits  form  which  turn 
it  gradually  into  a  stone  child  or  lithopaedion ;  in  this  condition 
it  may  be  retained  in  the  abdomen  of  the  mother  indefinitely. 

Interstitial  pregnancy  usually  ends  by  rupture  of  the  tube  just 
where  it  enters  the  uterine  wall  or  by  the  escape  of  the  ovum  into 
the  cavity  of  the  uterus. 

Ovarian  pregnancy  ends  in  rupture,  the  ovum  escaping  into  the 
abdominal  cavity  or  becoming  encysted,  possibly  developing. 
It  occasionally  happens  that  the  uterus  retains  to  some  degree  its 
foetal  form  and  development,  and  this  may  render  possible  the 
lodgment  and  growth  of  the  ovum  in  one  of  the  horns  of  the 
uterus ;  in  such  cases  the  ovum  may  develop  for  a  few  months, 
but  sooner  or  later  rupture  will  occur,  with  the  usual  symptoms 
before  narrated ;  in  exceptional  cases  an  ovum  develops  to  a 
period  of  viability  in  this  manner.  Cases  are  reported  of  an 
extra-uterine  pregnancy  followed  by  an  intra  uterine  pregnancy, 
the  ovum  in  the  first  case  dying  and  becoming  encysted,  and  its 
removal  by  operation  resulting  in  abortion  of  the  second  intra  - 
uterine  ovum.  In  cases  where  rupture  of  the  foetal  sac  occurs  and 
death  of  the  extra-uterine  foetus,  nature  often  regards  the  foetus 
as  a  foreign  body  and  seeks  to  remove  it  by  ulceration  into  the 
bladder  and  vagina  or  rectum ;  such  a  process  has  even  been 
observed  to  open  the  abdominal  wall  near  the  umbilicus. 

The  diagnosis  of  extra-uterine  or  ectopic  pregnancy  is  uncertain 
before  rupture  of  the  foetal  sac ;  it  is  rarely  positive  and  clear. 
Hence  those  methods  of  treatment  are  most  reliable  which  con- 
firm beyond  doubt  the  diagnosis  of  the  physician,  for  it  is  only 
by  careful  analysis  of  the  symptoms  of  each  case,  combined  with 
a  knowledge  of  the  pathology  of  such  cases,  that  the  physician 
can  hope  to  make  a  correct  diagnosis.  When  the  presence  of 
this  condition  is  suspected,  and  good  reasons  exist  for  the  suspi- 
cion, the  most  natural  theory  of  treatment  is  that  which  regards 
the  extra  uterine  ovum  as  a  foreign  body  to  be  treated  as  other 
foreign  bodies,  by  removal ;  efforts  have  been  made  to  kill  the 
ovum  by  the  application  of  electricity,  the  aspiration  of  fluid 
from  the  foetal  sac,  or  an  injection  into  the  ovum  of  morphia ; 


EXTRA-UTERINE   OR   ECTOPIC   PREGNANCY.  23 1 

the  first  of  these  expedients  has  in  some  cases  been  successful, 
the  second  and  third  are  rarely  successful,  and  none  of  these 
procedures  should  be  the  choice  of  the  physician.  When  'the 
patient  will  not  allow  the  physician  to  perform  or  have  performed 
laparotomy,  he  is  justified  in  giving  other  methods  of  treatment 
a  trial,  but  they  are  not  the  best  possible  expedients.  The  most 
desirable  treatment,  so  soon  as  rupture  occurs,  is  opening  the 
abdomen,  removing  the  ovum  and  its  appendages  with  the  rup- 
tured oviduct,  thereby  checking  the  haemorrhage  promptly.  Such 
is  the  education  of  the  modern  physician  that  no  one  should 
practice  obstetrics  who  is  not  prepared,  should  an  emergency  arise, 
to  operate  in  this  manner;  in  cities  where  specialists  and  hospitals 
abound,  a  conscientious  physician  will  often  summon  a  brother 
surgeon,  and  procure  for  his  patient  the  benefit  of  his  greater 
technical  skill ;  but  the  obligation  of  the  practitioner,  whether  he 
be  alone,  or  whether  in  easy  reach  of  assistance,  remains  the 
same,  namely,  that  he  either  controls  threatening  haemorrhage 
himself,  or  procures  for  his  patient  some  one  who  can  and  will 
do  it. 

After  the  removal  of  the  ovum  and  the  tube,  and  the  ligation 
of  bleeding  vessels,  the  abdomen  may  be  advantageously  irrigated 
with  hot  water ;  the  use  of  the  drainage  tube  may  be  determined 
upon  in  accordance  with  surgical  principles  which  are  generally 
taught.  In  cases  where  the  fcetus  is  expelled  by  suppuration,  the 
foetal  sac  should  be  treated  like  an  abscess  cavity ;  drainage  should 
be  carefully  maintained  through  the  aperture  by  which  the  fcetus 
has  been  extruded  ;  antiseptic  injections  should  be  made  into  the 
sac,  and  the  patient  supported  by  suitable  food  and  stimulants. 
In  cases  where  the  fcetus  has  developed  in  the  abdominal  cavity, 
the  obstetrician  may  delay  operation  until  the  fcetus  be  viable, 
provided  the  patient  is  under  observation  and  easily  accessible ; 
when  viability  has  been  reached,  the  abdomen  is  to  be  opened, 
the  fcetal  sac  incised,  and  the  fcetus  removed  and  resuscitated ; 
the  cord  should  be  ligated  and  cut  close  to  the  placenta.  No  effort 
should  be  made  to  separate  the  placenta  and  membranes  from 
their  attachments  if  these  attachments  are  formed,  and  such  effort 


232  MANUAL   OF    PRACTICAL   OBSTETRICS. 

causes  free  haemorrhage ;  the  membranes  should  be  sutured  to  the 
edges  of  the  lower  portion  of  the  abdominal  incision,  and  a  large 
drainage  tube  passed  into  the  foetal  sac ;  the  placenta  and  mem- 
branes will  be  gradually  eliminated  by  a  process  of  conservative 
necrosis ;  at  the  end  of  a  week  or  ten  days  the  placenta  can  be 
cautiously  removed,  and  the  cavity  left  will  gradually  close  by 
granulation  ;  during  this  process  this  cavity  should  be  treated  with 
antiseptic  applications. 

In  cases  of  interstitial  pregnancy  operation  should  consist  in 
the  removal  of  the  foetus,  and  the  amputation  of  the  uterine 
cornu  with  sufficient  resaction  of  the  uterine  wall,  if  necessary,  to 
bring  about  coaptation. 

It  must  also  be  observed  that  extra-uterine  pregnancy  must  be 
more  frequent  than  has  been  commonly  supposed,  and  that  a  consid- 
erable number  of  such  cases  terminate  in  spontaneous  recovery ; 
such  are  those  in  which  the  ovum  dies  in  the  oviduct  before  rup- 
ture ;  where  the  ovum  and  its  clot  become  encysted  immediately 
after  rupture  and  remain  inert  for  an  indefinite  time ;  the  existence 
of  such  a  possibility,  however,  cannot  lessen  the  responsibility  of 
the  physician  in  the  study  and  treatment  in  these  cases. 


CHAPTER  XXXV. 

POST-PARTUM   HAEMORRHAGE. 

BLEEDING  from  the  uterus  after  delivery  is  normally  prevented 
by  uterine  contractions,  whereby  the  muscular  fibres  of  the  uterus 
compress  its  sinuses.  The  condition  of  the  mother's  blood  at  the 
end  of  pregnancy  favors  rapid  and  firm  clotting  of  blood  in  the 
uterine  sinuses.  The  small  vessels  of  a  healthy  endometrium  do 
not  readily  rupture,  and  persistent  oozing  of  blood  from  the  en- 
dometrium does  not  occur  after  labor  in  a  healthy  woman. 

Arterial  bleeding  from  the  uterus  follows  extensive  laceration 
of  the  cervix  which  wounds  the  circular  artery  of  the  uterus. 
Ordinarily,  however,  lacerations  of  the  cervix  do  not  extend  suffi- 
ciently to  Wound  an  artery,  and  only  capillary  oozing  is  observed. 

Post-partum  haemorrhage  may  also,  follow  laceration  of  the 
vagina  and  pelvic  floor.  It  is  rare  to  observe  such  bleeding 
which  does  not  cease  spontaneously ;  the  hot  vaginal  douche 
followed  by  an  antiseptic  tampon  is  generally  sufficient  for  these 
cases  ;  if  not,  immediate  suture  is  required. 

'  As  post-partum  haemorrhage  is  most  frequently  uterine  haem- 
orrhage, the  obstetrician  is  especially  concerned  with  those  causes 
which  produce  the  relaxation  of  the  uterine  muscle  and  ensuing 
bleeding.  After  labor,  in  cases  where  the  uterus  has  been  over- 
distended  by  more  than  one  foetus  during  pregnancy,  haemorrhage 
may  be  feared,  as  an  overstretched  muscle  is  often  a  paretic 
muscle.  In  poorly-developed  women  the  uterine  muscle  is  ill- 
developed  in  common  with  the  voluntary  muscles,  and  relaxation 
after  labor  may  occur.  When  the  uterus  has  been  exhausted  in 
complicated  labor,  as  after  transverse  position  followed  by  version, 
haemorrhage  must  be  feared.  Infections  which  profoundly  affect 
the  mother's  blood,  rendering  it  less  coagulable  than  normally, 

10*  233 


234  MANUAL    OF    PRACTICAL    OBSTETRICS. 

favor  haemorrhage.  Shock  and  injury  to  the  nervous  system 
which  depress  the  nervous  supply  of  the  uterus  cause  relaxation 
of  the  uterine  muscle  and  haemorrhage. 

Many  cases  of  haemorrhage  are  caused  by  the  improper  con- 
duct of  labor.  Rapid  delivery,  failure  to  stimulate  the  uterus  to 
contract  by  friction  after  the  placenta  has  been  expelled,  remov- 
ing the  placenta  by  pulling  on  the  cord  and  failure  to  properly 
stimulate  the  nervous  system  of  a  weak  patient  are  among  the 
most  common  errors  producing  haemorrhage. 

The  symptoms  of  post-partum  haemorrhage  are  rapid,  soft 
pulse,  a  large  doughy  tumor  in  the  abdomen,  alarm  or  prostra- 
tion on  the  patient's  part,  with  thirst,  sudden  failure  of  vision  or 
sense  of  suffocation  and  the  discharge  of  blood  from  the  vagina. 
These  symptoms  are  mentioned  in  the  order  of  their  relative  im- 
portance. It  must  be  remembered  that  most  alarming  haemor- 
rhage may  occur  with  no  discharge  of  blood  for  several  minutes. 
Hence  the  wise  precept:  "Do  not  leave  a  woman  after  labor 
when  the  pulse  is  100,  or  above,"  as  there  is  a  liability  to  haem- 
orrhage. If  the  practitioner  is  intelligent  enough  to  detect  a 
relaxed  condition  of  the  uterus  before  blood  has  escaped  through 
the  vagina,  he  can  control  haemorrhage  before  it  becomes  dan- 
gerous. When  the  condition  of  the  pulse  excites  suspicion,  the 
abdomen  should  be  examined  at  once ;  the  firm  tumor  formed 
by  the  well-contracted  uterus  wrill  be  absent;  an  ill-defined  mass 
will  indicate  the  location  of  the  enlarged  and  relaxed  womb. 

Post-partum  haemorrhage  is  rare  in  cases  conducted  by  in- 
telligent physicians.  The  best  methods  of  conducting  labor 
favor  good  contraction  of  the  uterus  and  render  the  occurrence 
of  haemorrhage  infrequent.  When  the  uterine  muscle  is  not 
allowed  to  become  over-distended  by  delay  in  complicated 
labors ;  when  delivery  in  normal  labor  is  not  hurried ;  when 
time  is  taken  to  secure  a  normal  third  stage  of  labor  and  the 
placenta  is  delivered  by  expression,  haemorrhage  rarely  occurs. 

The  treatment  of  this  condition  consists  in  instantly  examining 
the  abdomen  so  soon  as  the  pulse  occasions  suspicion  or  blood 
flows  from  the  vagina.  Failing  to  find  the  well-contracted  ute- 


POST-PARTUM   HEMORRHAGE. 


235 


rus,  the  hand  is  placed  broadly  on  the  abdomen,  and  rapid  fric- 
tion, with  a  kneading  movement,  is  made.  The  uterus  will 
respond  better  to  rapid  light  massage  than  to  more  violent  and 
slower  manipulation.  As  soon  as  the  uterus  can  be  defined  by 
the  hand,  it  should  be  grasped.  The  fingers  are  best  placed 
behind  the  fundus,  deeply  in  the  middle  line  of  the  abdomen ; 
the  thumb  holds  the  uterus  in  the  middle  of  its  anterior  surface 
in  front ;  the  back  of  the  hand  is  above,  over  the  fundus.  Pres- 
sure should  be  made  in  the  axis  of  the  pelvis,  downwards  and 
backwards,  not  laterally.  In  lateral  pressure  an  enlarged  ovary 
may  be  compressed  between  the  hand  and  the  uterus,  and  sud- 
den, excruciating  pain,  with  symptoms  of  shock,  have  been  seen 
to  follow  such  compression. 

If  a  nurse  is  available,  she  may  give  the  patient  a  hot  vaginal 
injection  of  a  gallon  of  water  that  has  boiled,  at  a  temperature 
of  100°  F.  to  1 10°  F.,  while  the  physician  manipulates  the  uterus. 
Water  as  hot  as  the  nurse  can  taste  may  be  taken  in  the  lack  of 
more  accurate  measurement.  A  hypodermic  syringe  full  of  ergot 
(fluid  extract)  may  be  injected  deeply  into  the  subcutaneous  tissue 
at  the  sides  of  the  abdomen  ;  ergotine  may  be  employed  in  doses 
of  20  minims  in  the  same  manner.  If  the  uterus  contracts  under 
this  treatment,  the  hand  should  rest  upon  the  fundus,  without 
massage,  until  the  pulse  and  general  condition  of  the  patient 
warrant  the  belief  that  danger  is  over.  Several  large  towels  may 
then  be  taken  and  folded  in  suitable  pads.  One  is  to  be  placed 
across  the  abdomen,  behind  the  fundus ;  one  on  each  side  of  the 
uterus ;  a  broad,  firm  binder  should  then  be  pinned  firmly  around 
the  patient,  from  above  downward,  reaching  from  the  umbilicus 
to  the  trochanters.  Ergot  or  quinine  may  then  be  given  by  the 
mouth,  and  the  patient  put  perfectly  at  rest.  When  the  physician 
or  nurse  is  intelligent  in  observing  the  pulse,  it  is  safe  to  bandage 
the  uterus.  When  no  such  intelligent  care  is  available,  it  is  better 
not  to  apply  pads  and  bandage,  but  trust  to  the  hand  upon  the 
uterus,  with  constant  watchfulness. 

The  majority  of  cases  of  post-partum  uterine  haemorrhage  yield 
to  this  treatment  if  recognized  promptly.  When  the  physician 


236 


MANUAL   OF   PRACTICAL   OBSTETRICS. 


does  not  reach  his  patient  until  she  is  already  reduced  by  haemor- 
rhage, he  must  add  active  stimulation  to  the  treatment  described. 
The  patient's  head  should  be  lowered,  and  the  foot  of  her  bed 
raised  three  feet  and  more  higher  than  the  head.  Auto-transfusion 
and  the  injection  of  saline  solution  into  connective  tissue  spaces 
may  be  done  to  advantage.  Rectal  injections  of  whiskey  ^  2  and 
hot  milk  ^  2,  may  be  given.  If  massage,  ergot  and  hot  vaginal 
douches  fail  to  secure  uterine  contraction,  the  uterus  should  be 
douched  with  hot  water,  a  vaginal  douche  having  been  first  given. 

FIG.  in. 


TAMPONING  THE  UTERUS  FOR  HAEMORRHAGE. 


If  the  uterus  still  refuses  to  contract,  a  strip  of  iodoform  gauze 
four  feet  long  and  three  inches  wide  should  be  grasped  by  uterine 
dressing  forceps.  While  one  or  two  fingers  of  one  hand  guide  the 
forceps  to  the  os,  the  other  hand,  grasping  the  forceps,  should 
carry  the  end  of  the  gauze  to  the  fundus  of  the  uterus  (Fig.  in). 
The  mere  presence  of  a  strip  is  usually  enough  to  excite  contrac- 
tion, but  if  great  relaxation  is  present,  the  uterus  may  be  moder- 
ately tamponed,  the  remainder  of  the  strip  being  used  as  a 
vaginal  tampon.  This  strip  of  tampon  may  be  left  twenty-four 


POST-PARTUM    HEMORRHAGE.  237 

hours  if  antiseptic  precautions  have  been  carefully  observed.  It 
should  then  be  removed,  the  vagina  and  uterus  douched  with 
creolin,  2  percent.,  carbolic  acid,  2  percent.,  or  thymol  i  to 
1000,  and  if  needed,  the  tamponing  may  be  repeated.  In  the 
absence  of  iodoform  gauze,  bichloride  gauze,  or  a  roller  bandage 
or  strips  of  muslin  dipped  in  bichloride  solution,  i  to  10,000,  or 
whiskey  and  water,  may  be  used.  In  hospital  practice  a  Faradic 
battery  should  be  part  of  the  equipment  of  each  lying-in  ward, 
as  the  Faradic  current,  one  pole  over  the  uterus,  the  other  over 
the  spinal  cord,  is  of  value  in  these  cases. 

Vinegar  or  lemon-juice  squeezed  into  the  uterus,  or  a  lump  of 
ice  placed  in  the  uterus  are  domestic  remedies  which  are  useful 
in  the  lack  of  better. 

Where  nervous  prostration  and  excitement  are  present,  opium 
and  alcohol  are  of  advantage.  Morphia  gr.  ^  and  atropia  gr. 
•j-J-tf  hypodermically,  with  frequent  injections  of  ether  or  brandy, 
are  valuable  agents. 

Where  post-partum  haemorrhage  is  caused  by  rupture  or  lacera- 
tion of  the  uterus,  or  laceration  of  the  vagina,  surgical  treatment 
is  requisite.  The  extirpation  of  the  uterus  by  abdominal  incision ; 
immediate  suture  of  a  lacerated  cervix  or  vagina  are  indicated, 
and  under  antiseptic  precautions  may  save  life. 

It  occasionally  happens  that  bleeding  from  a  diseased  endome- 
trium,  or  bit  of  retained  placenta,  persists  after  labor  or  occurs  in 
the  puerperal  state.  Hot  antiseptic  intra-uterine  douches  are  first 
indicated;  in  the  event  of  their  failure,  the  uterus  should  be 
thoroughly  scraped  with  the  blunt  douche-curette  and  tamponed 
with  antiseptic  gauze.  Intra-uterine  suppositories  should  be  used 
for  several  days  after  the  removal  of  such  tampons. 

In  post-partum  haemorrhage  in  patients  whose  blood  is  pro- 
foundly impaired,  inhalation  of  oxygen  is  useful ;  in  malarial  cases, 
the  hypodermic  injection  of  30  grains  of  bisulphate  of  quinine  in 
freshly-made  camphor  water  has  been  found  of  value. 

During  convalescence  from  post-partum  haemorrhage,  inhalation 
of  oxygen  and  the  administration  of  arsenic,  with  or  without  iron, 
give  excellent  results. 


CHAPTER    XXXVI. 

THE   ACCIDENTS    OF   LABOR   ENDANGERING   THE   MOTHER. 

THE  mother's  life  maybe  suddenly  threatened  during  labor  by 
causes  which  modern  knowledge  of  the  physiology  and  pathology 
of  labor  has  enabled  the  obstetrician  to  foresee  and  prevent  in 
the  majority  of  cases.  One  of  these  accidents  which  is  largely 
preventable  is  rupture  of  the  uterus. 

When  the  expulsion  of  the  child  is  delayed  and  the  uterus  con- 
tinues to  contract,  the  upper  expulsive  segment  becomes  firmly 
contracted  in  a  condition  of  tetanus;  the  lower  elastic  segment  is 
distended  more  and  more  by  the  continued  pressure  from  above 
and  by  the  settling  down  of  the  presenting  part.  The  junction 
between  the  two  segments  is  marked  by  the  lower  edge  of  the 
upper  expulsive  segment  which  forms  a  firm  and  prominent  ring 
to  be  plainly  felt  on  palpation.  This  is  the  contraction  ring  of 
Bandl,  and  furnishes  a  symptom  of  threatened  uterine  rupture. 
If  the  uterine  tetanus  persists  and  delivery  is  not  accomplished, 
the  uterus  may  tear  asunder  just  below  the  contraction  ring,  on 
its  anterior  or  posterior  surface  ( Fig.  1 1 2). 

Uterine  rupture  occurs  in  cases  of  transverse  positions  of  the 
foetus,  where  labor  is  neglected  and  uterine  contractions  are  vig- 
orous. It  also  occurs  in  contracted  pelvis,  where  the  uterus  labors 
hopelessly  to  expel  the  child,  finally  tearing.  This  accident  is 
naturally  more  frequent  in  multipart  who  have  borne  many  chil- 
dren than  in  primiparae ;  also  in  multiple  labor  because  the  uterus 
has  been  over-distended  by  more  than  one  foetus.  Weak,  poorly- 
developed  women  are  more  exposed  to  this  accident  if  the  child 
be  large,  and  they  become  exhausted  in  labor. 

Symptoms  of  threatened  rupture  of  the  uterus  are  the  existence 
of  a  well  marked  contraction  ring;  rise  in  the  patient's  pulse  rate 
238 


THE  ACCIDENTS  OF  LABOR  ENDANGERING  THE  MOTHER.       239 
FlG.   112. 


CJL 


l.i. 


THREATENED  UTERINE  RUPTURE. 

/.  s.  Lower  uterine  segment ;   C.  K.    Contraction  ring  :  o.  i.    Internal  os  ;  a.  e.    External  os. 


240  MANUAL    OF    PRACTICAL    OBSTETRICS. 

and  temperature;  a  firm,  unyielding  condition  of  the  upper 
uterine  segment  detected  on  palpation,  and  the  exhaustion  and 
irritability  of  the  patient  which  are  seen  in  delayed  and  compli- 
cated labor.  The  presenting  part  can  often  be  felt  through  the 
abdominal  wall  projecting  above  the  brim  of  the  pelvis. 

Actual  rupture  of  the  uterus  is  characterized  by  sudden  cessa- 
tion of  uterine  contraction,  with  the  complaint  of  sudden  and 
excruciating  pain  by  the  patient,  followed  by  shock.  The  shape 
of  the  uterus  changes,  and  an  escaped  portion  of  the  foetus  can 
often  be  felt  through  the  abdominal  wall.  Haemorrhage  through 
the  vagina  may  or  may  not  be  present 

The  treatment  of  rupture  of  the  uterus  will  depend  upon  the 
extent  of  the  rupture  and  the  possibility  of  delivering  the  child 
through  the  vagina.  Where  the  uterus  tears  across  the  larger 
part  of  its  anterior  or  posterior  surface,  the  foetus  will  escape  into 
the  abdominal  cavity,  and  must  be  delivered  by  abdominal  in- 
cision. The  uterus  can  be  sutured  and  allowed  to  remain,  or 
removed  with  the  ovaries,  or  amputated  at  the  cervix.  Where 
but  a  partial  rupture  occurs,  the  obstetrician  will  endeavor  to 
deliver  the  child  through  the  vagina,  bringing  the  portion  of  the 
foetus  which  escaped  back  into  the  uterus  through  its  aperture  of 
ex't.  Version  should  be  avoided  if  possible  as  likely  to  increase 
the  rupture.  The  rent  in  the  uterus  may  then  be  tamponed 
through  the  vagina  with  iodoform  gauze,  which  is  brought 
out  through  the  vagina  as  a  drain,  or  a  drainage  tube  is  inserted 
and  gauze  is  packed  about  it.  Under  frequent  disinfection  of 
the  vagina  and  irrigation  through  the  uterine  rent  with  boiled 
water,  with  the  continued  use  of  the  tampon  or  drainage  tube, 
a  considerable  proportion  of  cases  of  partial  rupture  recover. 
In  complete  rupture,  if  delivery  be  effected  promptly  and  the 
uterus  be  skillfully  sutured  or  removed,  the  patient  may  recover. 
In  either  case  uterine  rupture  is  one  of  the  gravest  accidents 
of  labor. 

Where  rupture  is  threatened,  prompt  action  is  necessary.  It  is 
of  first  importance  to  secure  uterine  relaxation  and  relieve  the 
condition  of  uterine  tetanus  existing.  This  is  best  effected  by 


PJah-    X 


l>n\  IK'  Oh.stetries 


Transverse  Rupture  of  the  Anterior  Cervical  Wall. 
( Spiegelberg ) 


THE  ACCIDENTS  OF  LABOR  ENDANGERING  THE  MOTHER.       241 

deep  chloroform  anaesthesia,  this  anaesthetic  being  superior  to 
ether  for  such  cases.  The  injection  of  morphia  is  also  of  value, 
and  the  hot  bath  or  hot  applications  have  been  found  useful. 
Brandy  may  be  given  by  hypodermic  injection  in  free  doses.  If 
the  foetus  is  dead,  it  should  be  delivered  in  the  manner  least  likely 
to  injure  the  mother;  embryotomy  will  usually  be  advantageous. 


FIG.  113. 


VERSION  IN  THREATENED  RUPTURE  OF  THE  UTERUS. 


If  the  foetus  lives,  version  or  forceps  will  be  chosen,  as  the  pre- 
sentation and  dilatation  of  the  birth  canal  may  indicate  j  ver- 
sion before  uterine  rupture  and  under  deep  anaesthesia  being  a 
most  valuable  expedient  (Fig.  113). 


242  MANUAL   OF   PRACTICAL   OBSTETRICS. 

Foetal  mortality  in  threatened  and  actual  uterine  rupture  is 
very  high.  Long  continued  pressure  by  the  upper  uterine  seg- 
ment, and  the  inspiration  of  blood  and  abdominal  fluids,  where 
the  foetus  escapes  into  the  abdomen,  usually  kill  the  foetus  by 
asphyxia.  Its  chance  for  life  is  so  slight  that  it  is  commonly 
disregarded  in  the  presence  of  the  great  danger  which  threatens 
the  mother,  except  in  very  favorable  cases. 

INVERSION  OF  THE  UTERUS. — By  traction  upon  the  placenta 
through  the  cord,  by  sudden  violent  pressure  upon  the  fundus, 
and  by  spontaneous,  but  forcible  uterine  contractions,  the  womb 
may  be  inverted  or  turned  wrong  side  outward.  This  accident 
is  most  apt  to  happen  to  weak  and  exhausted  patients,  in  cases 
where  the  uterus  has  been  over-distended  during  pregnancy  and 
labor,  or  in  women  whose  muscular  development  is  deficient. 

Symptoms  of  inversion  of  the  uterus  are  pain,  shock  and  haem- 
orrhage and  the  appearance  of  a  uterine  tumor  in  the  vagina. 
This  tumor  may  vary  in  size,  from  a  mass  the  size  of  a  large 
orange  in  cases  where  the  fundus  only  is  inverted,  to  a  tumor  as 
large  as  a  man's  two  fists  hanging  between  the  thighs.  The 
diagnosis  of  an  inverted  uterus  is  not  always  easy.  A  prolapsed 
and  inverted  bladder  and  a  fibroid  polyp  of  the  uterus  may  simu- 
late the  inverted  uterus.  Should  the  placenta  be  adherent,  it 
will  be  at  once  evident  that  the  tumor  is  the  uterus.  A  diag- 
nosis in  these  cases  is  to  be  made  by  a  careful  examination.  The 
bladder  must  be  emptied  by  a  catheter ;  bimanual  examination 
will  reveal  the  absence  of  the  uterus  above  the  pubes,  and  an 
attempt  to  pass  a  sound  into  the  uterus  will  demonstrate  the  na- 
ture of  the  accident  (Fig.  114). 

Uterine  inversion  is  one  of  the  most  serious  accidents  of  labor. 
Death  from  exhaustion  soon  after  labor,  or  from  sepsis  if  the  pa- 
tient survives  the  accident,  commonly  results  when  inversion  is 
complete.  The  treatment  of  this  condition  consists  in  restoring 
the  uterus  to  its  normal  condition.  Pressure  by  the  antisepti- 
cized  hand,  the  uterine  tissue  being  protected  by  a  pad  of  anti- 
septic gauze,  should  be  immediately  made  upon  the  fundus,  in 
the  pelvic  axis.  While  force  must  be  exercised,  it  should  be 


THE  ACCIDENTS  OF  LABOR  ENDANGERING  THE  MOTHER.       243 

done  in  a  gentle,  steady  manner,  and  should  be  continued  for 
from  five  to  fifteen  minutes  at  a  time,  with  counter  pressure  over 
the  pubes.  The  patient's  general  condition  demands  attention 
in  these  cases;  antiseptic  douches  are  of  value  in  promoting 
reposition  and  preventing  sepsis,  and  pain  should  be  mitigated 
by  the  injection  of  morphia  and  atropia,  and  shock  combated 
by  the  injection  of  brandy  or  ether. 

If  the  physician  be  called  to  a  neglected  case  of  inversion  of 

FIG.  114. 


INVERSION  OF  THE  UTERUS. 

a  Upper  vaginal  wall.      b  The  inverted  uterus. 

the  uterus  in  which  septic  infection  is  threatened  by  an  infected 
uterus,  its  removal  will  afford  the  patient  her  best   chance  for 

life. 

LACERATION  OF  THE  CERVIX  UTERI  occurs  in  the  majority  of 
first  labors,  but  is  slight  in  extent.     Under  precautions  to  avoid 


244  MANUAL   OF   PRACTICAL   OBSTETRICS. 

septic  infection,  such  lacerations  heal  without  suture.  In  cases 
of  rapid  delivery,  and  in  spontaneous,  precipitate  labors,  lacera- 
tion extending  to  the  attachment  of  the  vagina  may  occur, 
causing  haemorrhage,  which  demands  treatment.  Immediate 
suture  is  the  proper  treatment  for  such  an  accident.  One  suture 
of  stout  silk,  catgut  or  silver  wire  on  each  side  will  commonly 
result  in  good  union.  If  the  patient  is  too  exhausted  to  permit 
of  suturing,  iodoform  gauze  tampons  may  be  used  to  check 
haemorrhage. 


CHAPTER    XXXVII. 

LACERATION   OF   THE   PERINEUM   AND   PELVIC   FLOOR. 

LACERATION  of  the  perineum  and  pelvic  floor  requires  the 
prompt  attention  of  the  physician.  This  accident  occurs  more 
frequently  than  many  practitioners  will  admit,  as  its  confession 
implies  a  want  of  skill  in  the  minds  of  many.  If  all  lacerations 
which  extend  beyond  the  fourchette,  or  posterior  commissure,  be 
called  laceration  of  the  perineum,  many  of  the  marvellous  records 
of  hundreds  of  cases  without  a  laceration  would  disappear.  Clini- 
cally, all  lacerations  which  extend  beyond  the  fourchette  should 
be  sutured  whenever  possible.  In  hospital  practice  this  can  be 
readily  accomplished ;  in  private  practice  the  physician  is  often 
led  to  omit  suture  and  depend  upon  spontaneous  union  under 
cleanliness.  It  is  true  that  union  often  results  in  laceration  of 
moderate  extent  without  suture,  but  such  treatment  is  not  the 
most  scientific  and  thorough.  It  is  the  rule  among  careful  obstet- 
ricians to  suture  all  lacerations  half  an  inch  in  length,  including 
the  posterior  commissure,  and  certainly  no  great  mistake  can  be 
made  by  following  this  rule. 

If  free  haemorrhage  exists,  a  tampon  of  gauze  may  be  applied, 
and  the  obstetrician  will  wait  for  several  hours  until  it  ceases. 
He  may  also  wait  for  daylight  and  to  secure  rest  for  his  patient 
to  advantage.  In  lacerations  not  extending  to  the  rectum,  silk 
or  silver  wire  may  be  used  to  advantage  for  suture  material.  In 
lacerations  to  or  through  the  bowel,  catgut  will  be  needed  in 
addition  to  the  other.  A  curved  needle  upon  a  handle  is  pre- 
ferred by  some ;  others  use  the  ordinary  curved  surgeon's  needle, 
in  needle  forceps.  The  patient  is  brought  to  the  edge  of  a  bed 
or  table,  her  feet  in  chairs  or  supported  by  assistants.  Except  in 
immediate  suture,  or  where  but  one  or  two  stitches  are  required, 

245 


246 


MANUAL   OF   PRACTICAL   OBSTETRICS. 


anaesthesia  is  necessary  for 
an  accurate  closure.  The 
operator  will  require  needles, 
needle-holder,  or  needle  on 
fixed  handle,  scissors,  a  pair 
of  tenaculum  forceps  or  a 
tenaculum,  a  pair  of  haemos- 
tatic forceps  and  suture  ma- 
terial. A  vaginal  douche  of 
a  gallon  of  bichloride  solu- 
tion, i  to  5000,  at  a  tempera- 
ture of  100°  F.,  may  first  be 
given.  Antiseptic  precau- 
tions having  been  taken  with 
the  operator's  hands  and  in- 
struments, a  simple  lacera- 
tion, as  shown  in  Fig.  115, 
is  to  be  closed  with  silk  or 
silver  wire,  by  passing  the 
sutures  beneath  the  entire 
wound  from  the  lower  end 
upwards.  The  letter  a  repre- 
sents the  highest  point  of  the 
laceration.  In  Fig.  116  the 
same  laceration  has  been  al- 
tered in  its  shape  by  drawing 
the  point  a  upwards  with  a 
tenaculum  forceps,  for  con- 
venience in  approximation. 

It  is  frequently  the  case, 
in  primiparge  especially,  that 
in  addition  to  a  central  tear 
in  the  perineum,  lacerations 
are  found  extending  up  into 
the  vaginal  tissues  on  one  or 
both  sides.  In  Figs.  117  and 


LACERATION   OF   THE    PERINEUM   AND    PELVIC   FLOOR.        247 


FIG.  118. 


FIG.  119. 


118  such  lacerations  and  their  closure  are  illustrated  by  diagrams, 
the  point  a  being  the  highest  point  in  the  true  perineal  laceration. 

In  Fig.  119  the  method  of  closing 
a  laceration  extending  into  the 
bowel  and  upwards  into  the  vagina 
on  each  side  is  illustrated.  The 
bowel  is  closed  from  within  out- 
wards by  stitches  of  fine  catgut,  and 
the  laceration  is  thus  converted  into 
one  illustrated  in  Fig.  120,  and 
closed  by  silk  or  silver  as  there  re- 
presented. When  an  obstetrician 
has  become  experienced  in  the  use 
of  catgut,  and  possesses  catgut  of 
good  quality,  he  may  close  perineal 
lacerations  by  the  continuous  catgut 
suture  as  shown  in  Figs.  121  and 
122.  Where  primary  union  does  not 
result  after  the  closure  of  perineal 
injuries,  in  eight  or  ten  days  after 
operation  the  patient  may  be  anaes- 
thetized, the  granulating  surfaces 
scraped  with  a  curette  and  closed 
by  suture.  If  thoroughly  done  this 
procedure  rarely  fails. 

The  after  treatment  of  these  cases 
consists  in  careful  antisepsis.  Three 
or  four  douches  to  the  perineum  and 
lower  portion  of  the  vagina  should 
be  given  in  twenty-four  hours  of 
bichloride  solution,  i  to  8000,  or 
creolin.  i  per  cent.  Antiseptic  pads 

or  napkins  should  be  kept  on  the  vulva.  The  use  of  the  catheter 
should  be  avoided,  and  the  parts  cleansed  after  each  urination  in- 
stead. Loose  bowel  movements  should  be  obtained  after  the  third 
or  fourth  day.  It  is  an  unnecessary  precaution  to  bind  the  legs 


FIG.  120. 


248 


MANUAL   OF   PRACTICAL   OBSTETRICS. 


FlG.   121. 


together  in  rational,  reasonable  patients.  If  the  sutures  do  not 
annoy  the  patient  they  may  remain  ten  days,  when  union  results. 
In  extensive  laceration  they  may  be  left  two  weeks.  The  patient 

should  remain  recumbent  for  at  least 
two  weeks  after  the  laceration  is 
closed. 

SUDDEN  DEATH  DURING  LABOR 
is  caused  by  the  formation  of  a  clot 
in  the  heart,  by  the  entrance  of  air 
into  the  circulation  through  the 
uterine  sinuses,  and  by  sudden  shock 
and  syncope  occurring  after  uterine 
rupture.  The  symptoms  of  threat- 
ened death  are  those  of  cardiac  syn- 
cope, faint  rapid  pulse  or  sudden 
cessation  of  the  pulse,  pallor  of  the 
features,  sudden  mental  alarm  and 

distress,  with  rapid  unconsciousness.  The  most  prompt  stimula- 
tion for  the  heart  and  brain  is  demanded.  Hypodermic  injec- 


o 


tions  of  ether,  raising  the  foot  of  the  bed  several  feet,  atropia, 
ammonia  and  brandy  or  whiskey  by  hypodermic  injection,  and 


LACERATION    OF   THE   PERINEUM   AND   PELVIC   FLOOR.        249 

where  oxygen  is  available  the  inhalation  of  this  gas  are  all  de- 
manded with  the  greatest  promptness.  Manipulations  to  accom- 
plish delivery  must  cease,  and  attention  be  given  to  resuscitating 
the  patient.  Unfortunately  many  of  these  cases  perish  before 
more  than  one  effort  can  be  made  to  save  them.  The  possibility 
of  heart-clot  and  the  entrance  of  air  through  the  placental  site 
should  be  borne  in  mind  in  cases  of  post-partum  hemorrhage, 
and  such  patients  should  not  be  allowed  to  sit  up  and  should  be 
prevented  from  sudden  exertion  so  far  as  possible.  In  removing 
a  placenta  in  these  cases,  as  little  violence  as  possible  should  be 
exerted,  and  uterine  contractions  maintained  by  pressure  and 
massage  over  the  uterus. 

THROMBOSIS  OF  THE  VEINS  ABOUT  THE  VULVA  AND  VAGINA  is 
an  accident  of  labor  which  may  result  from  violence  during  de- 
livery or  without  apparent  cause.  The  appearance  of  a  bluish- 
red  tumor  near  the  labium,  with  the  complaint  of  pain  on  the 
part  of  the  patient,  enables  the  physician  to  recognize  the  acci- 
dent. If  labor  can  be  completed  without  rupturing  the  tissues 
which  cover  the  thrombus,  care  should  be  exercised  that  the  ex- 
ternal air  does  not  find  entrance.  If  bleeding  goes  on  and  the 
thrombus  is  accompanied  by  the  extravasation  of  blood  into  the 
cellular  tissue  through  the  rupture  of  capillary  vessels,  the  tumor 
should  be  laid  open  under  careful  antiseptic  precautions,  the  clot 
turned  out  and  the  cavity  packed  with  antiseptic  gauze.  Labor 
should  then  be  completed,  and  a  compress  and  antiseptic  napkin 
worn  after  delivery.  The  after-treatment  of  such  a  cavity  con- 
sists in  its  thorough  -disinfection,  and  securing  healing  from  the 
bottom  by  the  continued  use  of  the  tampon.  When  labor  is 
completed  without  rupture,  an  antiseptic  pad  and  pressure  by  a  T 
bandage  will  favor  the  absorption  of  the  clot. 

In  difficult  delivery  by  forceps  or  version  and  extraction  the 
PUBIC  JOINT  has  been  RUPTURED.  This  accident  is  marked  by 
sudden  pain,  and  yielding  of  the  joint  which  is  appreciated  by  the 
physician.  It  may  or  may  not  be  accompanied  by  laceration  of 
the  tissues  beneath  the  pubes.  If  the  joint  surfaces  do  not  be- 
come infected  by  sepsis  compression,  by  plaster-of- Paris  bandage, 


250  MANUAL   OF    PRACTICAL   OBSTETRICS. 

or  by  a  firm  binder  is  sufficient.  Suppurating  arthritis  has  fol- 
lowed injury  to  the  pubic  joint  during  labor,  making  it  necessary 
to  drain  and  disinfect  the  articulation.  Recovery,  with  firm 
union,  usually  results  in  these  cases. 

In  sudden  death  during  labor  the  physician's  duty  to  the  un- 
born child  is  a  subject  of  interest  and  importance.  Immediate 
delivery  is  the  indication,  to  be  accomplished  as  the  circum- 
stances of  the  case  will  best  permit.  If  the  genital  canal  is  dilated 
and  the  head  or  breech  presents  the  forceps  may  be  found  effi- 
cient. In  multiparae,  where  the  foetus  is  not  favorably  situated 
for  the  application  of  forceps,  version  has  been  successful. 
Where  the  genital  canal  is  undilated,  the  extraction  of  the  child 
by  Csesarean  section  is  indicated  where  the  pregnancy  is  suffi- 
ciently advanced  to  give  reason  to  hope  that  the  foetus  can  sur- 
vive. 


CHAPTER   XXXVIII. 

PUERPERAL  SEPSIS  (PUERPERAL  FEVER). 

THE  most  important,  because  the  most  deadly  complication  of 
labor  and  the  puerperal  state  is  septic  infection.  At  the  present 
day  it  is  quite  needless  to  raise  the  question  as  to  the  nature  of 
puerperal  fever.  The  exact  mode  of  its  origin  may  not  be  clearly 
proven,  but  the  fact  that  it  is  an  infection,  produced  by  an  infecting 
agent  which  can  be  communicated,  rests  upon  grounds  beyond 
question.  By  puerperal  fever  we  do  not  refer  merely  to  rises  in 
temperature  occurring  after  labor;  such  fevers  will  be  considered 
later.  But  prolonged  variation  in  pulse  and  temperature  of  con- 
siderable degree,  accompanied  by  constitutional  symptoms  which 
denote  the  presence  of  an  actively  poisonous  agent,  and  by  anatomi- 
cal lesions,  necrotic  in  character,  form  together  a  clinical  picture 
formerly  named  puerperal  fever,  better  known  as  puerperal  sep- 
tic infection.  This  disorder  is  identical  with  septic  infection 
occurring  in  any  recently  wounded  patient,  whether  a  man 
crushed  by  machinery  whose  wounds  become  infected  during 
handling  by  a  careless  surgeon,  or  a  woman  whose  torn  perineum 
is  infected  during  labor  by  the  dirty  fingers  of  her  attendants. 
This  infection  is  produced  by  the  action  of  living  ferments,  which 
directly  destroy  the  tissue  or  plug  up  the  circulatory  channels  of 
the  body,  or  indirectly  poison  the  patient  by  producing  toxic 
alkaloids  which  are  absorbed. 

The  question  arises  as  to  whether  these  infecting  germs  are 
always  communicated  from  without,  or  whether  they  may  be 
found  independently  in  the  patient's  body;  in  other  words, 
whether  puerperal  infection  is  ever  auto-genetic.  While  it  is 
true  that  the  body  of  the  healthy  woman  never  contains  and  can 
never  develop  these  germs,  it  is  also  true  that  in  the  course  of. 

251 


252  MANUAL    OF    PRACTICAL    OBSTETRICS. 

diseases  previously  communicated  to  the  patient,  poisonous  agents 
are  introduced  which  gain  access  to  the  wounds  in  the  genital 
tract  made  during  labor,  and  produce  puerperal  sepsis  by  infect- 
ing these  wounds.  Thus  the  germs  of  gonorrhoea,  syphilis  or 
cancer  may  be  present  in  the  body  before  pregnancy;  and,  find- 
ing access  directly  to  the  circulation  through  the  wounds  of  labor, 
may  produce  sepsis. 

The  symptoms  of  puerperal  sepsis  will  be  best  understood  if 
we  remember  that  the  infecting  germs  may  gain  access  through 
the  lymphatics  of  freshly  made  wounds  in  the  vagina  and  vulva, 
or  go  directly  into  the  circulation  through  the  open  sinuses  at  the 
placental  site.  In  the  first  instance  vulvitis  and  vaginitis,  with 
the  formation  of  a  puerperal  ulcer,  develop,  in  three  or  four  days, 
from  contact  of  a  dirty  hand  or  instrument  in  the  vagina  after 
labor.  In  the  second  mode  of  septic  infection,  the  infected  hand 
of  a  careless  obstetrician,  who  performs  version  or  separates  and 
delivers  an  adherent  placenta,  lodges  infecting  germs  in  the  uterine 
wall,  where  the  placenta  was  attached,  and  direct  infection  through 
open  sinuses  results. 

The  course  of  puerperal  sepsis  can  best  be  comprehended  by 
recalling  the  anatomy  of  the  lymphatics  of  the  genital  tract,  as 
the  infection  usually  follows  the  course  of  these  channels.  The 
lymphatics  of  the  vulva  and  lower  fourth  of  the  vagina  commu- 
nicate with  the  superficial  inguinal  glands,  and  thence  through 
the  saphenous  opening  to  the  deep  inguinal  glands  or  along  the 
deep  blood-vessels,  finally  entering  the  abdominal  cavity.  An 
infection  planted  in  the  vulva  or  lower  portion  of  the  vagina 
may  finally  spread  to  the  peritoneum.  Considerable  time  would 
be  required,  however,  for  this  result  to  occur,  and  the  usual 
symptoms  of  vulvitis  and  vaginitis,  with  puerperal  ulcers  at  the 
posterior  commissure,  would  have  given  ample  warning  of  threat- 
ened danger. 

From  the  cervix  uteri  and  upper  three- fourths  of  the  vagina, 
the  lymphatics  communicate  with  the  deep  iliac  and  sacral 
glands.  Hence  a  focus  of  infection  in  the  uterine  cervix  or  in 
the  upper  part  of  the  vagina  readily  infects  the  peritoneum. 


PUERPERAL  SEPSIS  (PUERPERAL  FEVER).         253 

In  the  uterine  cavity  lymphatic  spaces  are  numerous  in  the 
uterine  decidua,  communicating  with  lymphatic  channels  in  the 
serous  covering  of  the  uterus.  From  this  surface  lymphatics  pass 
through  the  broad  ligaments  to  the  glands  situated  deeply  on  the 
posterior  wall  of  the  abdomen,  in  the  lumbar  region.  It  can 
readily  be  seen,  then,  how  direct  infection  of  the  uterine  decidua 
speedily  causes  peritonitis. 

The  least  dangerous  form  of  puerperal  sepsis  is  vulvitis  and 
vaginitis,  resulting  from  infection  of  the  vulva  and  lower  fourth 
of  the  vagina.  It  is  most  common  in  women  who  have  torn 
perinea  or  fissures  in  the  mucous  membrane  at  the  opening  of 
the  vulva.  In  forty-eight  to  sixty  hours  after  labor,  the  patient's 
temperature  rises  to  101°  F.,  or  102°;  slight  pain,  burning, 
smarting  on  micturition  are  felt  about  the  vulva ;  a  rigor  may  be 
experienced  by  nervous  patients.  The  pulse  is  100  to  120. 
On  examination  the  labia  are  swollen,  the  mucous  membrane 
reddened ;  at  the  posterior  commissure  abraded  or  lacerated  sur- 
faces are  found,  covered  by  a  yellowish  or  faintly  greyish  deposit. 
The  lochia  may  cease  for  a  short  time,  to  be  slightly  purulent  and 
offensive  later.  If  the  perineum  has  been  sutured,  the  surfaces 
will  not  be  healing  by  first  intention,  but  the  edges  of  the 
wound  will  be  separated  by  pus,  and  the  stitches  will  have  loos- 
ened slightly. 

The  treatment  of  this  condition  consists  in  douching  the  vulva 
and  lower  portion  only  of  the  vagina  with  bichloride  of  mercury 
solution,  i  to  5000,  douches  to  be  given  four  times  in  twenty-four 
hours.  Half  a  gallon  should  be  used  for  a  douche,  at  a  temper- 
ature of  100°  F.  The  physician  should  thoroughly  apply  to 
ulcerated  or  fissured  surfaces  peroxide  of  hydrogen  upon  absorbent 
cotton,  or  tincture  of  iodine  and  a  saturated  solution  of  carbolic 
acid  in  glycerine  equal  parts,  followed  by  the  free  use  of  iodo- 
form  or  boracic  acid  as  a  dusting  powder.  It  is  well  to  thor- 
oughly unload  the  bowels  by  calomel,  gr.  2*^,  and  soda,  gr.  10, 
followed  by  a  saline  or  an  abundant  hot  enema.  Abdominal 
pain  is  best  relieved  by  placing  upon  the  abdomen  a  flannel 
wrung  out  of  hot  water,  on  which  spirits  of  turpentine  have  been 


254  MANUAL   OF   PRACTICAL   OBSTETRICS. 

freely  sprinkled.  If  stitches  have  been  introduced,  they  should 
be  at  once  removed,  and  ununited  surfaces  freely  disinfected. 
The  patient's  diet  should  be  of  the  most  nutritious  and  digestible 
character,  and  alcohol  should  be  given  early  to  debilitated  pa- 
tients. 

In  cases  where  the  infection  begins  at  the  uterus  or  upper  por- 
tion of  the  vagina,  the  rapid  spread  of  septic  germs  soon  produces 
inflammation  of  the  tissues  about  the  uterus,  and  of  the  peritoneum 
which  covers  it.  The  first  is  /<?r/metritis ;  the  second,  para- 
metritis. 

The  symptoms  of  perimetritis  are  tenderness  on  deep  pressure 
at  one  or  both  sides  of  the  uterus,  with  pain,  fever  and  increased 
pulse  rate.  The  symptoms  of  parametritis  are  pain  on  deep 
pressure  directly  over  the  uterus,  swelling  of  the  abdomen,  with 
acute  pain  over  the  womb.  Parametritis  soon  merges  into  general 
peritonitis,  in  which  the  abdomen  becomes  distended,  very  pain- 
ful ;  the  pulse  rapid  and  feeble ;  fever  continually  high ;  while 
great  thirst,  prostration  and  often  delirium  complete  a  clinical 
picture  of  gravest  import.  If  a  vaginal  examination  be  made  in 
perimetritis,  parametritis,  or  general  peritonitis  following  either, 
an  exudate  will  usually  be  found  in  one  or  both  broad  ligaments, 
which  in  some  cases  fixes  the  uterus  as  in  a  mould.  Suppuration 
may  occur  in  these  cases,  and  pelvic  abscess,  limited  by  the  pelvic 
peritoneum,  which  becomes  inflamed  and  adherent,  is  frequently 
observed.  Following  parametritis  the  lymphatics  of  the  uterine 
muscle  become  infiltrated  with  septic  material,  the  muscle  becomes 
enlarged  and  softened,  and  metritis  is  said  to  be  present.  The 
wall  of  a  womb  which  is  the  seat  of  septic  inflammation  is  much 
softer  and  more  easily  perforated  than  normally,  and  hence  the 
need  for  caution  in  intra-uterine  manipulation  in  septic  cases. 

Septic  infection  of  the  uterus  produces  first  a  brief  cessation  of 
the  lochia,  and  then  purulent,  offensive  lochia.  The  occurrence 
of  the  symptoms  of  perimetritis  and  parametritis,  with  foul  lochia, 
leaves  no  room  for  doubt  that  the  uterine  cavity  is  in  a  septic 
condition.  Its  prompt  and  thorough  disinfection  is  the  impera- 
tive duty  of  the  obstetrician. 


PUERPERAL  SEPSIS  (PUERPERAL  FEVER).         255 

After  the  vagina  has  been  thoroughly  disinfected  by  a  copious 
vaginal  douche  of  bichloride  of  mercury  solution,  i  to  5000,  the 
uterus  should  be  explored  and  thoroughly  douched.  The  patient 
should  be  placed  across  a  bed  or  upon  a  table,  her  hips  at  the 
edge.  A  gallon  of  creolin  solution,  2  per  cent.,  carbolic  acid, 
2  per  cent.,  thymol  i  to  1000,  saturated  solution  of  boracic  acid, 
or  alcohol  i  part  and  water  2  parts  should  be  in  readiness,  at  a 
temperature  of  110°  F.  Bichloride  of  mercury  should  not  be 
used  for  intra-uterine  douches,  on  account  of  the  danger  of 
poisoning  which  attends  its  introduction  into  the  uterus.  As  an 
instrument  for  douching  the  uterus,  and  also  removing  retained 
portions  of  placenta  and  membranes  or  diseased  decidua,  the 
writer  has  found  Carl  Braun's  douche-curette  of  great  service. 
This  is  a  dull,  spoon-curette  upon  a  long,  hollow  handle,  which 
may  be  connected  with  the  hose  of  a  fountain  syringe.  The 
syringe  being  filled  with  the  antiseptic  solution  chosen  for  irriga- 
tion of  the  uterus,  which  is  allowed  to  run  through  the  curette, 
the  curette  is  gently  introduced,  the  cervix  being  steadied  if 
necessary  by  grasping  it  and  pulling  upon  it  by  a  tenaculum 
forceps.  While  the  antiseptic  fluid  continues  to  run,  the  endo- 
metrium  is  gently  but  thoroughly  scraped  by  the  curette,  and  thus 
the  double  purpose  of  an  intra-uterine  douche  and  an  exploration 
of  the  uterine  cavity  is  secured.  After  thorough  cleansing  of  the 
uterus  with  the  douche- curette,  a  suppository  containing  sixty 
grains  of  iodoform  is  grasped  by  uterine  dressing  forceps  and 
carried  well  within  the  uterine  cavity.  After  the  use  of  the  curette 
and  iodoform  suppository,  it  is  often  unnecessary,  and  even  inju- 
rious, to  enter  the  uterine  cavity  again  with  any  instrument.  If 
the  uterus  is  once  thoroughly  disinfected,  and  symptoms  of  septic 
infection  persist,  the  infecting  material  has  entered  the  blood  and 
must  be  combated  by  constitutional  treatment. 

If,  however,  the  physician  has  no  douche-curette  and  the  in- 
ternal os  is  not  firmly  contracted,  an  ordinary  glass  vaginal  douche 
tube  may  be  used.  The  stream  should  run  freely  through  the 
tube,  before  it  is  introduced,  to  prevent  the  entrance  of  air,  and 
the  bag  of  the  fountain  syringe  must  not  be  higher  than  three 


256  MANUAL   OF    PRACTICAL   OBSTETRICS. 

feet  above  the  patient's  bed.  Many  intra-uterine  douche  tubes 
are  in  market,  and  have  their  several  advocates.  In  common 
with  other  instruments,  that  which  is  simplest  and  most  easily 
cleaned  is  best.  We  have  found  an  intra-uterine  douche  tube 
of  hard  rubber,  made  in  two  pieces,  of  great  convenience.  In 
cases  where  it  is  difficult  to  enter  the  uterus,  this  tube  can  be  bent 
like  a  pessary  to  any  curve.  Its  simple  construction  admits  of 
its  easy  disinfection ;  the  upper  portion,  which  remains  in  the 
vagina,  forms  an  excellent  tube  for  washing  out  the  foetal  head 
after  craniotomy  (Fig.  123). 

Whatever  douche  tube  be  used,  a  fountain  syringe  and  the  force 

FIG.  123. 


HARD  RUBBER  INTRA-UTERINE  DOUCHE  TUBE. 

of  gravity  is  to  be  chosen  for  irrigating  the  uterus.  The  compres- 
sion bulb  syringe  is  not  to  be  selected  for  this  purpose,  from  the 
danger  of  the  entrance  of  air  and  difficulty  in  cleansing  the 
syringe.  At  least  a  gallon  of  hot  antiseptic  solution  should  be 
allowed  to  run  before  the  tube  is  removed  and  the  iodoform  sup- 
pository introduced.  The  effect  will  be  a  powerful  stimulation  of 
uterine  contraction  and  usually  a  fall  in  the  patient's  temperature. 
If  the  uterus  shows  a  tendency  to  relax,  ergot  or  quinine  may  be 
given  to  advantage.  Four  vaginal  douches  of  bichloride  solution, 
i  to  5000,  should  be  given  in  each  twenty-four  hours,  and  after 
a  douche  the  iodoform  suppository  may  be  repeated,  if  needed. 
If  the  first  disinfection  has  been  thorough,  it  will  rarely  be  neces- 
sary to  repeat  it,  and  the  frequent  use  of  intra-uterine  douches  is 
to  be  avoided.  When  foul  lochia  and  fever  persist,  an  intra- 
uterine  douche  may  be  given  once  daily  for  a  few  days. 

In  doubtful  cases  of  fever  after  child-birth,  it  is  the  obstetrician's 


PUERPERAL  SEPSIS  (PUERPERAL  FEVER).         257 

first  duty  to  examine  the  patient  carefully  for  signs  of  septic  in- 
fection. If  no  other  cause,  as  fecal  retention,  be  found  for 
fever,  the  genital  tract,  from  the  fundus  uteri  to  the  vulva,  should 
be  thoroughly  antisepticized.  By  so  doing,  sepsis  is  excluded,  a 
diagnosis  can  be  more  readily  made,  and  the  patient's  interests 
have  not  been  jeopardized. 

n* 


CHAPTER    XXXIX. 

THE   CONSTITUTIONAL   AND    SURGICAL  TREATMENT   OF    PUERPERAL 

SEPSIS. 

SCARCELY  less  important  than  the  disinfection  of  the  genital 
tract  is  the  constitutional  or  general  treatment  of  puerperal  sepsis. 
We  possess  at  present  no  antiseptic  which  may  be  introduced  into 
a  patient's  blood  in  quantities  sufficient  to  destroy  the  micrococci 
of  sepsis,  which  will  not  destroy  life,  with  the  possible  exception 
of  alcohol.  This  drug,  by  reason  of  this  property,  and  also  its 
utility  as  a  food,  is  especially  adapted  for  use  in  these  cases.  As 
a  rule,  beverages  containing  a  high  percentage  of  alcohol  are  best 
borne  and  most  advantageous.  Brandy  and  whiskey  diluted,  or 
alcohol  and  water,  are  often  tolerated  when  wines  are  refused. 
When  wines  can  be  taken,  port  and  sherry  are  best  adapted,  and 
maybe  taken  in  quantities  limited  only  by  the  patient's  tolerance. 
It  is  impossible  to  give  exact  rules  for  the  use  of  alcohol  in  sepsis. 
So  long  as  the  patient  is  not  intoxicated,  the  breath  not  smelling 
strongly,  the  pulse  becoming  slower  and  stronger  after  adminis- 
tration of  alcohol,  it  is  doing  good. 

With  the  administration  of  alcohol  goes,  with  equal  importance, 
the  giving  of  food.  Milk,  peptonized  if  needed,  eggs  beaten  up 
with  milk  or  whiskey,  or  brandy,  freshly  made  broths,  well  sea- 
soned and  served  hot,  are  the  basis  of  feeding.  Koumyss;  rich, 
pure  ice  cream;  milk,  curdled  by  rennet,  and  scraped  beef  may 
be  added  if  craved  by  the  patient,  and  well  borne. 

The  time  and  manner  of  feeding  and  giving  alcohol  cannot  be 
understood  without  reference  to  the  antipyretic  treatment  of 
puerperal  sepsis.  Of  the  various  modes  of  lessening  fever,  the 
application  of  cold  is  best.  Antipyretic  drugs  (antipyrin,  anti- 
febrin,  phenacetin)  are  of  value  only  as  nervous  sedatives.  Their 
use  in  doses  of  fifteen  to  twenty-five  grains  obscures  diagnosis 
258 


THE  CONSTITUTIONAL  TREATMENT  OF  PUERPERAL  SEPSIS.    259 

early  in  a  case  of  puerperal  sepsis,  lessens  the  patient's  strength, 
and  impairs  capacity  for  food  and  alcohol.  Antipyrin  in  5  grain 
doses,  phenacetin  in  5  grain  doses  and  antifebrin  in  2^  grain 
doses  relieve  nervous  restlessness,  and  favor  rest  and  sleep.  They 
often  take  the  place  of  opium  for  simple  restlessness,  without  its 
injurious  effects  on  digestion. 

When  fever  rises  to  the  point  of  oppressing  the  patient  (103°, 
104°,  105°  F.)  sponging  with  cold  water  should  first  be  tried. 
Where  cold  water  serves  to  depress  the  patient,  rapid  sponging 
with  hot  water,  to  which  ammonia  or  alcohol  has  been  added, 
may  be  substituted. 

In  either  case  heat  is  lost  by  evaporation  from  the  patient's 
skin.  If  this  suffices  to  refresh  the  patient,  half  an  ounce  of 
whiskey  or  brandy  and  a  small  cup  of  milk,  or  broth,  or  an  egg 
may  be  taken.  It  will  be  found  that  antipyretic  treatment  of  this 
sort  and  feeding  can  be  given  to  advantage  at  convenient  inter- 
vals, from  every  two  to  every  four  or  five  hours.  When  sponging 
does  not  suffice,  the  body  pack  is  convenient  and  useful.  This 
consists  in  exposing  the  patient's  trunk,  from  the  pubes  to  the 
episternal  pit.  Towels  are  then  wrung  out  of  ice  water,  and  laid 
across  the  body  from  the  pubes  to  the  neck.  By  the  time  the 
last  one  is  placed,  the  first  is  warm  and  should  be  removed,  wrung 
out  and  replaced.  By  wringing  them  out  in  rotation  an  efficient 
and  convenient  pack  is  obtained,  which  may  be  given  without 
wetting  the  patient's  bed.  The  whole  pack,  in  a  wet  sheet,  and 
the  cold  bath  are  less  often  needed.  In  parametritis  and  peri- 
tonitis the  ice  bag  or  better,  ice  water  coil,  placed  over  the  womb, 
is  useful.  The  pain  of  abdominal  and  pelvic  inflammation  may  be 
often  relieved  by  turpentine  stripes  or  by  cold.  When  very  severe, 
it  must  be  controlled  by  morphia  and  atropia  hypodermically. 

The  treatment  of  peritonitis  by  salines  is  useful  only  in  the 
first  few  days  of  the  attack.  An  eliminating  diarrhoea  is  fre- 
quently observed  in  these  cases  and  should  not  be  checked  unless 
excessive,  when  salicylate  of  bismuth  in  thirty  grain  doses  will  be 
found  useful.  So  far  as  tonics  are  concerned,  quinine  in  five  grain 
doses,  with  pepsin,  is  of  advantage  in  greatly  debilitated  patients. 


260  MANUAL   OF    PRACTICAL    OBSTETRICS. 

THE  SURGICAL  TREATMENT  OF  PUERPERAL  SEPSIS  is  of  import- 
ance, because  a  more  extended  trial  of  this  resource  may  lessen 
the  mortality  of  this  disease.  When  pelvic  abscess  can  be  diag- 
nosticated, it  should  be  emptied  and  disinfected,  either  through 
the  vagina  or  by  supra-pubic  incision.  The  symptoms  of  such 
abscess  are  an  elastic  tumor  felt  through  the  vagina  beside  the 
uterus,  following  septic  infection,  with  the  general  symptoms  of 
pyaemia. 

When  a  collection  of  pus  can  be  diagnosticated  in  the  perito- 
neum, encysted  by  peritoneal  inflammation  and  adhesions,  incis- 
ion and  drainage  are  indicated.  Continued  peritoneal  inflamma- 
tion; protrusion  of  a  portion  of  the  abdominal  wall  with  an  area 
of  well  marked  dullness,  are  diagnostic  signs  of  encysted  peri- 
toneal abscess.  The  utility  of  laparotomy  when  diffuse  general 
septic  peritonitis  is  present  is  still  a  subject  of  investigation,  and 
is  not  proven. 

In  puerperal  sepsis  of  pyaemic  character,  abscesses  may  form  in 
the  serous  cavities  of  the  body  including  the  joints,  and  by  for- 
mation of  septic  thrombi  and  emboli  in  the  connective  tissues. 
Incision  and  drainage,  with  thorough  antisepsis,  is  the  only 
treatment. 

In  puerperal  sepsis,  infecting  emboli  and  thrombi  may  be  car- 
ried to  any  of  the  organs  of  the  body.  Thus  an  area  of  a  lung 
may  become  infected  by  the  lodging  of  an  infected  embolus,  and 
septic  pneumonia  results.  Hepatic,  cerebral  and  splenic  abscess 
have  a  like  origin.  Multiple  joint  emboli  may  simulate  rheuma- 
tism. Sudden  blindness,  followed  by  the  rapid  destruction  of  an 
eye,  denotes  that  an  embolus  has  reached  the  eye.  The  state- 
ments of  those  who  do  not  practise  antiseptic  precautions  in  ob- 
stetrics, and  deny  septic  mortality  are  explained,  in  part  at  least, 
when  we  find  that  such  practitioners  lose  patients  from  "malaria," 
from  " pneumonia "  and  "jaundice"  after  confinement.  A  better 
knowledge  of  the  pathology  of  puerperal  sepsis  would  have  enabled 
them  to  recognize  in  these  cases  the  late  complications  of  puer- 
peral septic  infection. 


CHAPTER    XL. 

COMPLICATIONS   OF   THE    PUERPERAL   STATE. 

IN  addition  to  septic  infection,  the  puerperal  patient  is  exposed 
to  several  complications  which  affect  her  recovery  and  the  well- 
being  of  her  child.  The  interests  of  both  are  involved  in  dis- 
orders of  the  breasts,  and  MASTITIS  and  ENGORGEMENT  of  the 
breasts  are  among  the  most  common  of  these  disorders. 

ENGORGEMENT  results  from  sudden  distention,  and  from  neglect 
to  support  the  breasts  and  favor  the  free  discharge  of  milk.  The 
glands  become  greatly  enlarged,  the  skin  over  them  tense  and 
shining,  the  veins  well  marked  and  the  axillary  lymphatics  en- 
larged and  tender.  Lancinating  pain  is  felt,  extending  into  the 
axillae.  A  rise  in  temperature  to  100°  F.,  and  in  nervous  women 
a  sensation  of  chilliness  may  be  present,  but  no  well  marked  rigor 
occurs,  and  the  sharp  disturbance  which  characterizes  septic  infec- 
tion is  absent  The  condition  of  engorgement  predisposes  to 
inflammation  by  causing  congestion,  but  suppuration  and  septic 
fever  do  not  occur  unless  a  micrococcus  finds  access  to  the  breasts 
through  some  fissure  of  the  nipple  or  from  the  infected  blood  of 
the  mother. 

When  pain  and  swelling  of  the  breasts  occur  the  obstetrician's 
first  duty  is  to  assure  himself  that  septic  infection  is  not  present. 
Simple  engorgement  having  been  diagnosticated,  the  indications 
are  to  support  and  compress  the  breasts,  to  promote  the  free  exit 
of  fluid  from  them,  and  to  promptly  drain  the  lymphatic  chan- 
nels of  the  mother  of  a  considerable  quantity  of  fluid.  The  com- 
plaint of  pain  is  to  be  met  by  the  application  of  heat  or  cold, 
whichever  the  patient  finds  most  grateful. 

The  breasts  may  be  conveniently  supported  and  compressed  by 
the  breast  binder,  which  has  been  described  in  the  treatment  of 

261 


262  MANUAL   OF   PRACTICAL    OBSTETRICS. 

the  normal  puerperal  state.  By  tightening  or  loosening  the  band- 
age and  shoulder  straps,  and  by  observing  that  the  apertures  for 
the  nipples  are  large  enough  to  permit  fluid  to  flow  easily,  the 
bandage  will  be  of  considerable  service.  Fluid  may  be  removed 
from  the  engorged  breasts  by  the  breast  pump,  the  simple  bulb 
pump  being  best.  The  prompt  use  of  saline  laxatives  will  pro- 
mote the  subsidence  of  the  engorgement ;  a  teaspoonful  of  a  satu- 
rated solution  of  magnesium  sulphate,  given  every  hour  or  half 
hour  until  free  watery  stools  are  voided,  will  be  found  useful. 
Over  the  bandage  may  be  placed  an  ice-bag,  or  hot  fomentation, 
as  is  most  conducive  to  the  patient's  comfort.  Her  diet  should 
be  light,  and  fluid  taken  as  sparingly  as  possible.  The  child  may 
nurse  at  regular  intervals  ;  should  symptoms  of  intestinal  irritation 
appear,  it  may  be  fed  for  several  meals  until  the  secretion  of  fully 
formed  milk  is  established. 

MASTITIS. — Septic  infection  may  find  access  to  the  breasts  and 
produce  inflammation  and  suppuration.  This  complication  of  the 
puerperal  state  commonly  accompanies  the  development  of  gen- 
eral septic  infection,  the  infecting  material  gaining  access  to  the 
gland  through  a  fissure  in  the  nipple.  Mastitis  is  most  often  seen 
in  women  with  poorly  developed  nipples,  where  the  efforts  of  the 
child  to  nurse  wound  the  epithelial  covering  of  the  nipple,  and 
infectious  material  from  the  vagina  or  the  child's  mouth  enters 
through  the  abrasion. 

Symptoms  of  mastitis  are  pain,  tenderness  and  swelling  of  the 
gland,  with  lymphangitis.  The  lymphatics  of  the  breast  show  in 
reddened  lines,  the  axillary  lymphatics  are  large  and  tender,  and 
a  decided  rise  in  pulse  and  temperature,  with  often  a  pronounced 
rigor,  complete  the  clinical  picture.  Infection  finding  lodgement 
at  the  nipple  may  remain  limited  to  the  areola  and  tissues  about 
the  nipple,  or,  following  the  lymphatics  deeper,  may  infect  an 
acinus  of  the  gland  or  several  acini.  Suppuration  soon  follows, 
and  fluctuation  can  be  detected  on  careful  examination.  In  ne- 
glected cases  the  gland  may  become  honey-combed  by  suppura- 
tion, and  the  pus  may  burrow  in  the  axilla. 

When  the  nipples  are  developed  during  pregnancy,  the  epithe- 


COMPLICATIONS  OF  THE  PUERPERAL  STATE.       263 

lium  healed  by  ointments,  and  antiseptic  precautions  are  exer- 
cised in  the  conduct  of  labor,  mastitis  is  infrequent.  When  it 
occurs,  it  should  be  treated  by  the  measures  advised  for  the 
treatment  of  engorgement,  with  prompt  incision  and  disinfection 
when  pus  forms.  A  suppurating  breast  is  to  be  treated  like  any 
other  abscess.  The  child  is  to  be  taken  from  the  affected  breast 
at  once. 

CHECKING  LACTATION. — When  the  fetus  dies  and  when  the 
mother  proves  unable  to  nurse  her  infant,  the  secretion  of  milk  must 
be  checked,  to  prevent  engorgement  and  threatened  mastitis.  Com- 
pression by  the  bandage,  the  application  of  cold,  if  the  patient  is 
not  depressed  by  it,  and  the  use  of  belladonna  are  indicated.  A 
convenient  and  comfortable  way  of  applying  belladonna  consists  in 
cutting  a  circular  piece  of  surgeon's  lint,  with  an  aperture  to  permit 
the  nipple  to  protrude,  smearing  belladonna  ointment  upon  it, 
placing  it  upon  the  breast  and  applying  the  compressing  band- 
age over  it.  The  breast  should  be  disturbed  as  little  as  possible, 
tension  being  relieved  by  the  cautious  use  of  the  breast  pump, 
which  does  not  require  the  removal  of  the  bandage. 

Where  an  ointment  is  objectionable,  a  similar  piece  of  lint  may 
be  sprinkled  with  a  solution  of  atropia,  four  grains  to  the  ounce, 
and  applied  in  the  same  manner.  An  eruption  resembling  that 
produced  by  croton  oil  occasionally  follows  the  use  of  bella- 
donna, but  does  not  cause  serious  inconvenience. 

Simple  FISSURE  of  the  NIPPLES  will  occasion  pain  when  the  child 
nurses,  and,  unless  precautions  are  taken  to  avoid  infection,  soon 
ends  in  inflammation.  Scrupulous  cleanliness  and  the  free  use 
of  boracic  acid  solution  are  indicated ;  the  nipple  must  be  pro- 
tected by  a  nipple  shield,  and  the  application  of  an  ointment  of 
equal  parts  of  cosmoline  and  lanoline,  with  ten  grains  of  boracic 
acid  to  the  ounce,  or  painting  with  the  compound  tincture  of 
benzoin,  will  usually  result  in  speedy  cure.  In  neglected  cases 
nitrate  of  silver  may  be  required. 

The  tardy  contraction  of  the  genital  tract  to  nearly  its  former 
dimensions  is  known  as  SUB-INVOLUTION.  Septic  infection  and 
inflammation,  retention  of  portions  of  the  placenta  and  mem- 


264  MANUAL    OF    PRACTICAL   OBSTETRICS. 

branes,  and  failure  in  the  patient's  nutrition  and  vigor  are  the 
most  common  causes.  When  the  uterus  continues  large,  and  the 
vaginal  walls  remain  relaxed  and  engorged  with  blood,  the  phy- 
sician's first  duty  is  to  ascertain  that  no  pathological  condition 
within  the  uterus  is  causing  sub-involution.  The  womb  should 
be  explored  with  the  curette  and  thoroughly  douched  with  a  hot 
antiseptic  solution.  An  iodoform  or  boracic  acid  suppository 
may  then  be  left  within  the  uterine  cavity.  The  vagina  should 
be  examined  to  see  that  no  ulcerated  surface  is  present.  Lacera- 
tion of  the  cervix  and  perineum  and  vagina  may  be  closed  after 
the  first  ten  days  of  the  puerperal  period,  and  if  antisepsis  be 
practised,  such  operations  will  be  attended  by  little  or  no  dis- 
turbance of  the  patient's  general  condition. 

The  constitutional  treatment  of  sub-involution  is  scarcely  less 
important  than  the  local  treatment  of  the  genital  tract.  Consti- 
pation must  be  avoided  ;  massage,  judicious  feeding,  the  admin- 
istration of  ergot,  arsenic  and  nux  vomica  or  strychnia,  and  oxy- 
gen are  of  great  service.  The  upright  posture  is  to  be  avoided 
for  a  considerable  time ;  the  patient  can  walk  with  less  injury 
than  when  she  remains  standing.  The  avoidance  of  improper 
clothing  is  also  of  great  advantage  in  preventing  constriction  of 
the  abdomen,  forcing  the  abdominal  viscera  downwards,  and 
favoring  prolapse  of  the  genital  tract. 

In  cases  in  which  the  bowels  are  not  properly  moved  during 
pregnancy,  fecal  accumulation  exists  to  a  considerable  degree. 
Unless  especial  precautions  be  taken  to  empty  the  large  intestine 
thoroughly  soon  after  labor,  FECAL  TOXAEMIA  may  occur.  The 
absence  of  pain  or  tenderness  about  the  genital  tract ;  rapid  pulse ; 
fever  (102-103°  F.);  perspiration;  furred,  coated  tongue;  and 
apathy  and  discomfort,  with  loss  of  appetite,  are  the  usual  symp- 
toms of  this  condition  in  the  puerperal  patient.  After  a  careful 
examination  has  established  the  absence  of  septic  infection,  free 
purgation  will  speedily  terminate  the  disorder.  The  value  of 
copious  hot  rectal  injections  in  these  cases  is  to  be  kept  in  mind. 

Fever  in  the  puerperal  patient  may  also  follow  EMOTIONAL  DIS- 
TURBANCE. A  diagnosis  in  these  cases  must  be  made  by  closely 


COMPLICATIONS  OF   THE    PUERPERAL   STATE.  265 

watching  the  patient  and  her  surroundings,  after  a  thorough 
physical  examination  has  excluded  septic  or  other  acute  infection 
and  fecal  intoxication.  The  removal  of  the  perturbing  cause, 
with  the  administration  of  a  sedative  addressed  to  the  nervous 
system,  will  speedily  end  the  fever. 


CHAPTER    XLI. 

RETENTION    OF    THE    PLACENTA. 

WHILE  in  normal  cases  the  placenta  is  expelled  within  half  an 
hour  after  the  birth  of  the  child,  it  is  occasionally  retained.  It  is  to 
be  remembered  that  a  retained  and  an  adherent  placenta  are  very 
different  in  pathology  and  indications  for  treatment.  Simple  re- 
tention of  the  placenta  results  from  atony  of  the  uterine  and  abdom- 
inal muscles,  and  usually  follows  exhausting,  complicated  labors. 
In  women  of  deficient  physical  development,  in  those  whose  nerv- 
ous system  has  been  greatly  taxed  by  labor,  and  in  cases  where  care 
has  not  been  taken  to  secure  good  contractions  of  the  uterine  and 
abdominal  muscles  after  the  foetus  is  expelled,  placental  retention 
frequently  results.  When  summoned  to  such  a  patient,  the  physician 
will  find  the  relaxation  produced  by  exhaustion,  or  the  tetanic, 
irritable  contraction  of  the  uterus  which  follows  exhaustion  of  the 
nerve  centres  in  some  cases,  demanding  his  attention.  After 
carefully  antisepticizing  the  vagina  and  his  hands,  a  thorough  vagi- 
nal examination  will  inform  him  regarding  the  case. 

In  atony  and  relaxation  he  will  find  the  placenta  in  the  lower 
uterine  segment  and  cervix,  an  edge  of  placental  tissue  often  accessi- 
ble to  his  grasp.  His  left  hand  should  rub  the  uterus  to  secure  tonic 
contraction,  and  placing  the  thumb  in  the  centre  of  the  fundus 
and  the  flexed  four  fingers  behind  the  uterus,  it  should  be  com- 
pressed downwards  and  slightly  backward.  Care  should  be  exer- 
cised that  the  uterus  is  grasped  in  the  centre  and  kept  in  the  central 
line  of  the  abdomen,  as  otherwise  an  enlarged  ovary  may  be  com- 
pressed, and  violent  pain  and  shock  be  inflicted.  The  fingers  in 
the  vagina  will  be  able  to  assist  in  bringing  the  placenta  into  the 
vagina,  whence  it  can  be  readily  delivered.  This  method  of 
uterine  compression  and  placental  delivery  is  known  as  Crede's. 
266 


RETENTION   OF   THE    PLACENTA.  267 

Where  the  placenta  is  retained  by  a  contracted  but  exhausted 
uterus,  the  condition  of  uterine  tetanus  must  be  first  removed  be- 
fore the  placenta  can  be  delivered.  So  long  as  no  haemorrhage 
occurs,  the  pulse  remaining  good  and  the  uterus  readily  outlined 
in  the  abdomen,  rest  without  interference  is  often  all  that  is 
necessary.  Under  careful  observation  the  patient  may  remain 
quiet  for  half  an  hour  or  an  hour,  when  massage  will  often  cause 
a  normal  contraction  of  the  uterine  and  abdominal  muscles,  and 
the  placenta  will  be  expelled.  When  the  patient's  condition  de- 
mands the  immediate  removal  of  the  placenta,  an  anaesthetic 
should  be  given,  when  the  condition  of  tetanic  contraction  will 
yield  and  the  placenta  may  be  delivered  by  C  rede's  method. 
Chloroform  is  especially  useful  in  these  cases.  In  patients  greatly 
prostrated  by  prolonged  and  difficult  labor,  the  hypodermic  use 
of  morphia  and  atropia,  and  also  brandy,  may  be  indicated  before 
anaesthesia  can  be  prudently  commenced. 

ADHERENCE  OF  THE  PLACENTA  AND  MEMBRANES  is  the  result  of 
previous  endometritis  accompanying  syphilis,  gonorrhoea,  or  endar- 
teritis  of  the  vessels  of  the  endometrium  of  unknown  origin.  In 
these  cases  the  usual  efforts  at  placental  expulsion  are  made  by 
the  patient,  but  the  placenta  remains  wholly  or  partly  adherent 
to  the  uterine  wall.  This  is  among  the  most  trying  and  danger- 
ous of  the  complications  of  labor  and  the  puerperal  state.  The 
indications  are  to  remove  the  placenta  and  membranes,  as  the 
normal  forces  of  labor  cannot  do  so,  and  yet  the  effort  to  empty 
the  uterus  may  result  in  violence  and  infection  to  the  interior  of 
the  uterus.  Under  the  most  careful  antiseptic  precautions,  with 
anaesthesia,  a  gentle  but  patient  and  thorough  effort  must  be 
made  to  introduce  the  fingers  or  the  entire  hand  within  the 
uterus,  peel  off  the  placenta  and  membranes  and  remove  them. 
The  finger-tips  should  be  turned  toward  the  centre  of  the  uterine 
cavity,  away  from  the  wall  of  the  womb,  to  avoid  wounding  the 
endometrium,  while  the  fingers  separate  the  placenta  as  a  paper- 
knife  passes  between  the  leaves  of  a  book.  After  the  removal  of 
the  placenta  the  uterus  should  be  thoroughly  disinfected,  and  an 
antiseptic  suppository  left  within  the  cavity. 


268  MANUAL   OF   PRACTICAL   OBSTETRICS. 

When,  however,  the  placenta  cannot  be  removed  without  vio- 
lence, the  obstetrician  will  do  well  to  wait  until  necrosis  of  the 
cellular  tissue  where  the  placenta  and  uterine  wall  join  has  oc- 
curred, when  the  placenta  can  be  removed.  It  is  of  the  greatest 
importance  that  the  genital  tract  be  carefully  maintained  in  an 
aseptic  condition  during  this  time.  Four  vaginal  douches  of 
bichloride  of  mercury  i  to  5000  may  be  given  in  24  hours.  The 
patient  should  wear  an  antiseptic  occlusion  dressing  over  the 
vulva.  Her  temperature  is  to  be  watched,  and  at  any  considera- 
ble rise  the  uterus  must  be  emptied  and  disinfected.  If  infection 
can  be  prevented,  in  a  few  days  the  placenta  will  have  been  loos- 
ened by  innocuous  necrosis  without  suppuration.  It  is  well  to 
thoroughly  curette  the  uterus  after  the  delivery  of  such  a  placenta, 
to  remove  diseased  decidua  and  endometrium. 


CHAPTER    XLII. 

DISORDERS   OF    THE    FOETAL   APPENDAGES. 

AMONG  the  most  common  of  the  disorders  of  the  foetus  and  its 
appendages  is  DECIDUAL  ENDOMETRITIS.  Its  cause  is  not  clearly 
known,  but  several  forms  have  been  observed.  Polypoid ;  diffuse  or 
hypertrophic ;  cystic,  and  catarrhal  changes  in  the  decidua  have 
been  described.  Catarrhal  inflammation  of  the  decidua  may  occa- 
sion confusion  in  diagnosis,  from  the  fact  that  the  discharge  of  a 
catarrhal  secretion  occurs  during  pregnancy,  which  may  be  mis- 
taken for  a  discharge  of  amniotic  fluid.  When  the  fluid  is  closely 
observed,  however,  it  will  be  found  to  be  a  mucous  secretion  instead 
of  the  yellowish  amniotic  liquid.  When  inflammation  of  the 
decidua  persists,  it  not  infrequently  causes  foetal  death.  It  is  not 
amenable  to  treatment,  and  the  physician  can  only  confine  him- 
self to  curing  endometritis  when  the  patient  is  not  pregnant. 

ADHESION  OF  THE  AMNION  and  compression  of  the  foetal  limbs  is 
a  frequent  cause  of  malformation  in  the  foetal  members.  Webbed 
fingers  and  toes  are  often  seen  as  a  result  of  this  condition.  Am- 
putation of  a  foetal  limb  also  follows  this  complication.  Deficiency 
in  the  amniotic  liquid  (oligohydramnios)  often  accompanies  amni- 
otic adhesions,  and  malformations  of  the  lower  extremities  are 
ascribed  to  this  pathological  condition. 

Excess  of  amniotic  fluid,  POLYHYDRAMNIOS,  may  be  diagnosti- 
cated by  an  unusual  and  symmetrical  distension  of  the  abdomen, 
with  unusual  mobility  of  the  foetus  on  palpation,  and  faint  foetal 
heart  sounds  on  auscultation.  It  is  sometimes  dangerous  by  reason 
of  the  excessive  size  of  the  abdominal  tumor  and  the  enormously 
distended  uterus  which  may  threaten  rupture.  Pregnancy  is  often 
interrupted  by  the  over-distended  condition  of  the  uterus,  and  at 
labor  malpositions  of  the  foetus  are  caused  by  the  sudden,  free 
escape  of  an  excess  of  fluid.  » 

269 


270  MANUAL   OF   PRACTICAL   OBSTETRICS. 

Ordinarily  it  is  not  necessary  to  interrupt  pregnancy  because  of 
polyhydramnios,  but  caution  should  be  observed  at  labor  to  avoid 
a  malposition  of  the  foetus  and  prevent  precipitate  labor.  In 
excessive  polyhydramnios,  fluid  may  be  cautiously  withdrawn  by 
an  aspirator  needle  or  trocar. 

The  chorionic  villi  which  form  the  placenta  are  occasionally 
the  seat  of  a  myxomatous  degeneration  which  produces  a  VESICULAR 
MOLE.  When  the  disease  occurs  before  the  formation  of  the  pla- 
centa, the  entire  chorion  may  become  involved  ;  when  limited  to 
the  placenta,  the  affection  occasionally  destroys  the  placenta 
entirely,  substituting  a  mass  of  vesicles  or  cysts  for  normal  pla- 
cental  tissue.  Symptoms  of  myxoma  of  the  chorion  or  vesicular 
mole  are  rapid  increase  in  the  size  of  the  abdomen,  uterine 
haemorrhage  at  irregular  intervals,  and  the  discharge  of  grape-like 
cystic  bodies.  The  death  of  the  foetus  commonly  follows  this 
condition  ;  interference  is  rarely  indicated  except  in  cases  where 
the  excessive  growth  and  bleeding  of  the  degenerated  villi  threaten 
the  patient's  strength,  when  the  uterus  should  be  emptied. 

The  PLACENTA  may  be  the  seat  of  syphilis,  producing  gummata, 
infiltration  of  the  perivascular  spaces,  with  cellular  proliferation 
occluding  the  vascular  spaces  of  the  placenta.  A  syphilitic  pla- 
centa is  larger,  heavier  and  paler  than  normal,  and  islands  of 
syphilitic  tissue  can  be  detected  by  their  grayish-yellow  color. 
In  non-syphilitic  cases  endarteritis  of  the  placenta  is  also  observed, 
of  unknown  origin.  Apoplexy  of  the  placenta  results  in  destroy- 
ing the  function  of  limited  areas,  and  such  areas  may  be  recog- 
nized by  hsematine  staining,  visible  on  inspection.  Fatty  and 
calcareous  areas  are  observed  in  placentas  otherwise  normal,  and 
in  cases  where  the  foetus  is  normal. 

The  UMBILICAL  CORD  may  be  abnormally  long,  or  deficient  in 
length.  The  first  condition  predisposes  to  the  formation  of  knots 
and  coils  about  the  foetus,  and  may  lead  to  foetal  death  by 
asphyxia.  A  short  cord  may  occasion  delay  in  labor  by  prevent- 
ing the  descent  of  the  foetus,  and  may  result  in  premature  separa- 
tion of  the  placenta. 

The  coiled  condition  of  the  cord  about  the  foetus  may  be  diag- 


DISORDERS   OF   THE   FCETAL   APPENDAGES. 


,271 


nosticated  in  some  cases  by  the  detection  of  a  murmur  in  the 
cord.  When  a  sound  synchronous  with  the  foetal  heart  sound, 
and  complicated  by  a  murmur  resembling  a  very  faint  cardiac 
murmur  can  be  heard,  a  presumptive  diagnosis  of  a  cord  coiled 
about  the  foetus  may  be  made.  A  positive  diagnosis  cannot  be 
established  before  labor.  When  the  head  is  born  and  the  cord 
is  found  coiled  around  the  neck,  the  endeavor  should  be  made 
to  slip  it  over  the  head  or  shoulders  by  loosening  it  with  gentle 
traction.  Failing  in  this,  it  should  be  ligated,  and  delivery 
hastened.  The  foetus  is  often  asphyxiated  in  these  cases. 

Prolapse  of  the  cord  during  labor  threatens  the  life  of  the  foetus 
from  compression  and  asphyxia.  An  endeavor  may  be  made  to 
replace  a  prolapsed  cord  by  passing  a  doubled  piece  of  silk  liga- 
ture or  a  string  through  an 
English  catheter,  bringing  it 
out  at  the  eye,  passing  it  about 
the  cord  and  catching  the 
loop  of  ligature  over  the  end 
of  the  catheter.  By  pulling 
upon  the  ligature  at  the  end 
of  the  catheter  the  cord  can 
be  kept  firmly  grasped  while 
the  catheter  and  cord  are 


FIG.  124. 


passed  into  the  uterus ;  then 
the  ligature  is  slackened,  the 
catheter  withdrawn  and  the 
ligature  slips  off  the  end  of 
the  catheter,  leaving  the  cord 
in  the  uterus  (Fig.  124). 

The  most  efficient  treat- 
ment of  prolapsed  cord  con- 
sists in  anaesthetizing  the  pa- 
tient and  placing  her  in  the 
left  lateral  or  knee  chest  position.  If  this  is  impossible  she  may  lie 
across  a  bed,  with  her  hips  at  the  edge  and  raised  several  feet 
above  her  shoulders.  The  cord  is  then  grasped  by  the  antisepti- 


REPLACING  THE  CORD  WITH  A 
CATHETER. 


272  MANUAL   OF    PRACTICAL   OBSTETRICS. 

cized  hand  and  carried  into  the  uterus  and  placed  above  the 
foetus.  If  it  cannot  be  felt  to  pulsate,  or  if  it  persistently  prolapses 
when  the  grasp  of  the  physician  is  relaxed,  the  child  should  be  at 
once  delivered  by  version  and  resuscitated  if  possible. 


CHAPTER  XLIII. 

DISORDERS   OF   THE    FCETUS. 

THE  foetus  while  in  the  womb  is  subject  to  disease  and  to  mal- 
formations, which  may  cause  its  destruction  or  complicate  labor. 

EXCESS  OF  DEVELOPMENT  in  the  foetus  occasions  difficult  labor 
and  the  effort  to  complete  delivery  often  results  in  injury  which 
may  prove  fatal.  In  performing  version  and  extracting  a  large 
child,  fracture  of  the  clavicle  not  infrequently  occurs.  In  bring- 
ing down  an  arm  when  it  has  become  extended  in  breech  labor 
the  humerus  is  not  infrequently  fractured.  Such,  however,  are 
rarely  compound  fractures,  but  are  what  are  known  as  "green 
stick ' '  fractures,  in  which  the  periosteum  is  not  ruptured,  but 
the  fragments  are  retained  as  the  pieces  of  a  sapling  are  held  by 
its  thickened  bark.  These  cases  require  simple  retention  dress- 
ings, and  union  without  deformity  usually  results. 

Injuries  to  an  unusually  LARGE  FCETAL  HEAD  by  forceps  were  con- 
sidered when  treating  of  that  instrument.  As  the  surgical  treat- 
ment of  complicated  labor  becomes  better  known  and  more  ex- 
tensively practised,  the  conservative  abdominal  operations  will 
render  the  extensive  and  often  fatal  injuries  to  the  head  caused 
by  the  irrational  use  of  forceps  to  become  practically  unknown. 

DEFICIENCY  IN  FCETAL  DEVELOPMENT,  when  it  causes  a  sym- 
metrical but  undersized  foetus,  results  in  precipitate  labor  in  vigor- 
ous women.  Should  a  small  foetus  assume  a  complicated  position, 
it  can  be  most  safely  delivered  by  version,  as  the  grasp  of  the 
forceps  is  not  secure  upon  a  small  head. 

The  after  treatment  of  ILL-DEVELOPED  CHILDREN  requires  the 
exercise  of  great  care  and  patience.  When  such  infants  show  a 
persistent  tendency  to  abnormally  low  temperature,  they  should 
be  kept  in  an  incubator,  and  removed  only  when  necessary  to 

273 


274  MANUAL   OF   PRACTICAL   OBSTETRICS. 

obtain  food  or  maintain  cleanliness.  A  simple  but  efficient  in- 
cubator may  be  prepared  by  using  an  ordinary  large  clothes- 
basket  as  a  crib,  and  surrounding  the  child  by  bags  of  sand, 
which  may  be  heated.  If  an  abundance  of  padding  be  supplied 
and  a  sufficient  number  of  sand-bags,  so  that  some  can  be  con- 
stantly heating  while  others  are  changed,  a  temperature  of  100° 
F.  can  be  readily  maintained.  More  elaborate  and  efficient  in- 
cubators are  Tarnier's  and  Auvard's  simpler  form  of  Tarnier's, 
in  which  hot  water  supplies  heat. 

In  ill-developed  children  who  have  not  strength  sufficient  to  suck 
the  breast,  it  is  often  necessary  to  obtain  milk  by  a  breast-pump  and 
feed  it  to  the  child  by  a  spoon  or  medicine  dropper.  Milk  may 
be  introduced  into  the  stomach  by  passing  a  small  soft  catheter 
into  the  stomach,  attaching  a  funnel  to  it  and  pouring  milk 
through  the  funnel ;  this  is  known  as  gavage.  By  the  use  of  the 
incubator  and  by  careful  feeding,  the  age  of  viability  for  infants 
has  been  advanced  to  6^  in  place  of  7  months. 

The  presence  of  a  TUMOR  in  some  portion  OF  THE  FCETAL  BODY 
may  threaten  foetal  life  and  complicate  labor.  Such  are  a  con- 
genitally  enlarged  thyroid  gland  producing  goitre ;  enlarged 
spleen  from  malaria  or  sarcoma  ;  sacral  tumors  associated  with 
defect  in  the  walls  of  the  spinal  canal  and  the  protrusion  of  the 
membranes  and  fluid ;  cerebral  meningocele  or  deficient  cranial 
walls  with  protrusion  of  the  brain  and  its  membranes  and  fluids ; 
and  hydrocephalus.  In  all  of  these  cases  the  continuance  of  the 
child's  life,  even  if  labor  be  successfully  accomplished,  is  very 
doubtful.  Hence  the  mother's  interest  must  be  wholly  para- 
mount, and,  before  the  foetus  becomes  impacted,  embryotomy  is 
indicated.  The  most  common  of  these  conditions  is  that  of  dropsy 
of  the  cerebral  ventricles,  with  distention  of  the  brain  and  its 
coverings.  This  pathological  state  varies  in  severity  from  cases 
associated  with  rhachitis,  in  which  recovery  ensues,  to  instances  of 
excessive  distention  of  the  brain  and  cranium,  in  which  cerebral 
functions  and  even  the  continuance  of  life  are  impossible. 

The  presence  of  a  HYDROCEPHALIC  SKULL  is  diagnosticated  by 
feeling  a  smooth,  slightly  elastic  tumor  without  bony  landmarks 


DISORDERS   OF   THE   FCETUS. 


275 


in  place  of  the  ordinarily  ossified  head.  Examination  under 
anaesthesia  with  the  greater  portion  of  the  hand  will  confirm  the 
absence  of  the  sutures  and  fontanelles.  Delayed  or  suspended 
labor  results  from  the  presence  of  a  hydrocephalic  head  of  con- 
siderable size.  The  mistake  of  applying  the  forceps  to  such  a 
head  must  be  avoided ;  the  grasp  of  the  instrument  would  be 
insecure,  and  slipping  and  wounding  of  the  mother's  tissue  would 
result.  The  head  must  be  lessened  in  size  by  evacuating  a  por- 
tion of  the  fluid.  When  the  distention  of  the  head  is  not  exces- 

FIG.  125. 


LABOR  DELAYED  BY  HYDROCEPHALIC  HEAD. 

sive,  a  fine  trocar  may  be  employed,  in  the  hope  that  when  a 
portion  of  the  fluid  has  been  removed,  labor  pains  may  compress 
and  expel  the  head.  Where  the  head  is  so  large  that  no  such 
result  can  be  reasonably  expected,  it  is  best  to  perform  craniot- 
omy,  empty  the  head  of  a  considerable  portion  of  the  fluid,  and 
deliver  it  by  the  cranioclast  (Fig.  125). 

The  hydrocephalic  head  not  infrequently  lodges  in  the  fundus 


276  MANUAL   OF   PRACTICAL  OBSTETRICS. 

of  the  uterus,   the   foetus  assuming  a  breech  presentation.     In 
these  cases  craniotomy  on  the  after-coming  head  is  the  most 

FIG.  126. 


HYDROCEPHALUS  AND  BREECH  PRESENTATION. 

effective  treatment.  When  the  skull  cannot  be  readily  reached, 
the  spinal  canal  may  be  opened  and  fluid  drained  in  that  man- 
ner (Fig.  126). 


CHAPTER    XLIV. 
MONSTERS:  FCETAL  DEATH  IN  UTERO. 

DEFICIENT  development  in  various  portions  of  the  foetal  body 
causes  deformities  so  unnatural  in  appearance  that  such  a  foatus  is 
called  a  monster.  Single  monsters  (a  single  deformed  foetus)  are 
often  the  blighted  one  of  twins,  the  living,  normal  foetus  having  so 
appropriated  the  tissue  and  pabulum  of  the  other  that  but  a  portion 
of  the  body  has  developed.  Monsters  may  be  conveniently  divided 
into  those  which  can  exist  alone  (autositic)  and  those  which  depend 
upon  the  placental  circulation  of  a  second  foetus,  so  that  the  mon- 
ster's life  ceases  when  the  umbilical  cord  is  cut  (omphalositic). 

Among  the  autositic  monsters  are  the  ectro-melic,  with  the  ab- 
sence of  a  limb;  symelic,  the  limbs  joined ;  celosomatic,  the  abdom- 
inal wall  almost  entirely  deficient ;  exencephalic,  the  cranial  bones 
lacking;  pseudencephalic,  brain  and  cranial  bones  but  slightly 
developed;  anencephalic,  with  brain  and  skull  lacking;  cycloce- 
phalic,  eyes  fused ;  otocephalic,  ears  joined,  face  lacking.  The 
omphalositics  are  the  portions  of  a  blighted  twin,  the  other  normally 
developed.  They  are  deficient  in  cardiac  formation  (acardiac), 
or  have  no  head  (acephalic),  or  lack  a  trunk  (asomatic),  or  have 
no  well-defined  shape  (foetus  amorphous)  (Fig.  127). 

Double  monsters  are  most  often  joined  twins,  or  a  normal 
foetus,  with  several  limbs  or  parts  of  a  second  foetus  joined  to  the 
body  of  the  first. 

Although  even  double  monsters  are  often  delivered  sponta- 
neously, yet  should  impaction  and  delay  in  labor  occur,  ernbry- 
otomy  should  be  at  once  performed. 

DIAGNOSIS  AND  TREATMENT  OF  FOETAL  DEATH  IN  UTERO. — 
When  foetal  death  occurs  it  may  be  diagnosticated  by  the  cessa- 
tion of  heart  sounds  and  movements.  Progressive  diminution  in 
the  size  of  the  mother's  abdomen  is  also  a  symptom  of  diagnostic 

277 


278 


MANUAL   OF    PRACTICAL   OBSTETRICS. 


importance.  If  no  interference  be  practiced,  a  dead  foetus  is 
usually  expelled  spontaneously  in  less  than  a  month  after  the  foetal 
death.  If  retained,  it  may  become  soaked  in  amniotic  fluid  and  the 
serum  of  its  own  blood  (macerated) ;  or  shrivelled  (mummified) ;  or 

FIG.  127. 


ANENCEPHALIC  MONSTER. 

hardened  (a  lithopsedion).     Putrefaction  will  not  take  place  unless 
air  gains  access  to  the  foetus  through  rupture  of  the  membranes. 

When  foetal  death  has  been  diagnosticated,  labor  should  be  in- 
duced by  a  bougie.  If  the  foetal  membranes  have  been  ruptured 
and  putrefaction  be  present,  dilatation  must  be  cautiously  ef- 
fected, the  foetus  removed  and  the  uterus  disinfected. 


CHAPTER    XLV. 

DISEASES   OF   THE    NEW-BORN   CHILD. 

FAILURE  of  oxygenation  of  the  foetal  blood  is  a  common  dis- 
order attending  labor  and  persisting  for  a  few  hours  during  the 
puerperal  state.  It  is  commonly  known  as  ASPHYXIA,  and  is  of  two 
degrees.  The  first  is  that  in  which  the  child's  color  is  dark  red, 
the  heart  beats  slowly,  the  mouth  grasps  the  physician's  finger,  the 
reaction  to  counter-irritants  is  present,  respiratory  movements  are 
present  although  feeble.  This  condition  is  often  accompanied  by 
cerebral  compression  from  haemorrhages  on  the  surface  of  the 
brain,  following  compression  of  the  skull  during  labor.  Where 
haemorrhage  is  not  present,  efforts  at  resuscitation  are  commonly 
successful. 

The  second  stage  of  asphyxia  is  the  "pallid  asphyxia"  of  some 
observers.  The  child's  body  is  a  bluish-white;  the  muscles  re- 
laxed ;  feeble  efforts  at  respiration  or  deglutition  are  present ;  a 
very  feeble  heart  impulse  can  be  observed.  The  eyes  react  but 
slightly  to  light.  In  these  cases  treatment  is  often  unavailing. 
Children  suffering  from  diseases  which  make  the  establishment  of 
respiration  impossible  through  constitutional  weakness  often  survive 
labor  for  several  hours  or  a  day.  Such  children  have  gasping 
respiration;  are  red  in  color;  lie  in  a  condition  of  stupor;  moan 
in  an  unconscious  manner,  and  swallow  nourishment  with  diffi- 
culty. When  an  autopsy  is  made  on  such  a  child,  a  condition  of 
atelectasis  is  commonly  found  in  the  lungs.  The  portions  into 
which  air  has  not  entered  sink  in  water,  are  dark  red  or  violet  in 
color,  show  a  smooth  surface  when  cut,  with  no  mucus  on  pressing 
upon  the  cut  bronchial  tubes. 

The  treatment  of  asphyxia  has  been  already  stated  under  the 
treatment  of  labor  in  breech  presentation.  Children  who  have 

279 


280  MANUAL   OF    PRACTICAL   OBSTETRICS. 

been  resuscitated  from  asphyxia  should  be  kept  in  an  incubator 
for  several  days,  and  require  careful  attention  as  regards  the  main- 
tenance of  the  circulation  and  the  promotion  of  nutrition. 

SEPTIC  INFECTION  IN  THE  NEW-BORN  CHILD. — Septic  infection 
may  find  lodgment  in  the  child's  body  through  the  umbilicus  or 
a  mucous  surface.  Among  the  latter  varieties  of  sepsis  are  septic 
imflammation  of  the  conjunctivae,  of  the  mouth,  and  in  female 
children  of  the  vulva.  The  first  results  in  ophthalmia  neonatorum. 

The  symptoms  of  ophthalmia  of  the  new-born  are  redness  and 
swelling  of  the  lids,  with  a  muco-purulent  secretion.  If  allowed 
to  go  on,  infiltration  and  sloughing  of  the  cornea,  with  perfora- 
tion and  intra-ocular  abscess,  may  destroy  sight. 

In  proportion  as  antiseptic  precautions  are  taken  regarding  the 
condition  of  the  mother's  genital  tract  before  labor  and  the  avoid- 
ance of  infection  during  labor,  ophthalmia  disappears.  When  the 
gonococcus,  however,  is  present  in  the  vagina  before  labor  and 
infects  the  eyes,  the  after-treatment  is  often  unsuccessful.  In 
many  hospitals  a  drop  of  a  2  per  cent,  solution  of  nitrate  of  silver  is 
dropped  into  the  eyes,  after  douching  them  with  boiled  water.  In 
hospital  practice  this  precaution  gives  excellent  results.  Where 
the  genital  tract  is  known  to  be  aseptic  before  delivery,  it  is  un- 
necessary. So  soon  as  the  disorder  is  recognized,  if  one  eye  only 
is  affected,  the  other  should  be  closed  and  protected  by  an  anti- 
septic pad  and  bandage.  The  inflamed  eye  is  then  to  be  douched 
with  a  saturated  solution  of  boracic  acid  every  hour  or  half  hour, 
in  alternation  with  bichloride  of  mercury  solution  i  to  8  or  10,- 
ooo.  This  is  best  accomplished  by  placing  the  warmed  solution 
in  a  fountain  syringe,  using  a  medicine-dropper  in  place  of  the 
usual  nozzle.  The  child  is  placed  across  the  nurse's  lap,  its  arms 
confined  by  a  blanket,  its  inflamed  eye  lying  lower  than  the  other. 
While  the  lids  are  gently  separated  with  the  fingers  of  one  hand, 
with  the  other  the  stream  is  directed  from  the  nasal  side  of 
the  lids  to  the  outer  canthus.  The  fluid  is  conducted  by  a  rubber 
sheet  into  a  receptacle  and  thus  infection  of  the  other  eye  is 
avoided.  The  eyes  should  never  be  wiped  or  rubbed  with  bits 
of  cotton  as  is  so  often  done.  It  is  well  to  dilate  the  pupils  with 


DISEASES    OF   THE    NEW-BORN   CHILD.  281 

atropia  early  in  the  case.  Where  swelling  and  redness  are  exces- 
sive, compresses  dipped  in  an  iced  solution  of  boracic  acid  may  be 
kept  constantly  upon  the  lids.  The  occasional  application  of  a 
solution  of  silver  nitrate,  20  grs.  to  the  ounce,  is  useful  in  severe 
cases,  if  it  can  be  done  by  a  thoroughly  competent  person.  The 
infection  of  ophthalmia  is  very  virulent,  and  great  care  must  be 
exercised  by  nurses  and  attendants  to  avoid  the  transmission  of 
the  virus. 

Umbilical  sepsis  is  marked  by  redness  and  swelling  of  the  um- 
bilical tissues,  with  fever.  Occasionally  the  infection  passes  di- 
rectly through  the  lymphatics  into  the  general  circulation,  while 
no  local  symptoms  are  present.  Various  micrococci  may  cause 
umbilical  sepsis,  among  them  the  germ  of  erysipelas. 

The  mouth  may  be  invaded  by  various  forms  of  bacteria.  Most 
common  is  a  fungus  called  the  sprue  fungus,  which  forms  white 
patches  upon  the  mucous  membrane.  It  occasions  considerable 
irritation,  and  may  be  swallowed  and  disturb  the  intestinal  func- 
tions. It  is  best  treated  by  allowing  the  child  to  swallow  slowly 
a  teaspoonful  or  half  teaspoonful  of  solution  of  boracic  acid, 
from  5  to  10  per  cent,  in  strength,  given  with  some  palatable 
vehicle,  several  times  daily.  Where  boracic  acid  is  used  freely  in 
cleansing  the  nipple,  the  development  of  sprue  (or  thrush)  is  rare. 

In  diphtheritic  inflammation  of  the  vagina  at  labor,  the  diph- 
theritic virus  may  become  transferred  to  the  child's  mouth,  and 
set  up  a  like  process  in  the  fauces. 

The  child  may  inspire  septic  material  from  the  vagina  during 
complicated  labor,  in  which  asphyxia  is  threatened  and  respiratory 
movements  occur.  Inspiration  pneumonia  follows,  and  is  often 
fatal 

Malignant  jaundice,  tetanus,  acute  haemoglobinuria  of  the 
newborn  are  the  results  of  infection  by  agents  not  yet  clearly 
known  :  the  results  of  these  infections  are  fatal,  treatment  being 
simply  palliative.  Haemoglobinuria  is  associated  with  cyanosis, 
jaundice  and  hemorrhages  from  various  organs;  the  disease  is 
called  by  Winckel,  hsemoglubinuria.  The  bacillus  of  tetanus 
usually  finds  entrance  through  the  umbilicus. 


282  MANUAL   OF    PRACTICAL   OBSTETRICS. 

THE  UMBILICUS  may  be  also  the  seat  of  haemorrhage  after  the 
ligation  and  cutting  of  the  cord.  This  may  arise  from  fungous 
granulations  or  from  a  brittle  condition  of  the  blood  vessels.  If 
pressure  by  an  antiseptic  pad  fails  to  stop  such  haemorrhage,  two 
needles  may  be  passed  at  right  angles  beneath  the  bleeding  tissues 
and  a  figure-of-eight  ligature  applied. 

Besides  the  caput  succedaneum,  which  disappears  in  a  few  days 
after  labor,  CEPHALH^EMATOMA  may  be  present.  This  is  a  tumor 
formed  by  the  extravasation  of  blood  between  the  periosteum  and 
cranial  bones,  usually  situated  on  or  near  a  parietal  bone,  and 
varying  in  size  from  a  walnut  to  an  apple.  The  blood  is  dark, 
like  syrup.  The  tumor  is  not  painful,  and  has  a  tense,  hard  edge. 
If  the  tumor  be  opened,  the  blood  reaccumulates. 

Cephalhaematoma  may  also  be  internal,  the  blood  being  situ- 
ated between  the  bone  and  internal  periosteum.  External  cephal- 
haematoma  is  rarely  dangerous ;  when  internal  it  is  accompanied 
by  the  symptoms  and  dangers  which  mark  cerebral  compression. 

Cephalhaematoma  may  be  left  to  be  absorbed  spontaneously, 
or  incised,  emptied  and  compressed.  If  incised  it  should  be 
done  six  or  eight  days  after  the  tumor  is  discovered.  If  antiseptic 
precautions  be  observed,  incision  may  be  practiced  with  impunity. 

THE  BLOOD  of  the  newborn  infant  may  become  so  disordered 
that  passive  haemorrhage  from  the  mucous  surfaces  may  threaten 
the  child's  life.  When  the  blood  is  very  fluid  and  very  dark  in 
color  the  condition  is  known  as  melaena  neonatorum.  Such  dis- 
organization of  the  blood  is  invariably  fatal. 

SYPHILIS  and  RHACHITIS  are  among  the  most  important  of  the 
constitutional  and  deforming  diseases  of  the  foetus.  The  former 
is  known  by  the  pallid,  clay-colored  complexion  of  the  foetus ; 
the  coryza  which  is  present  at  birth  in  many  cases,  and  the  pem- 
phigoid  eruption  which  appears  a  few  days  after  birth  over  the 
whole  body.  If  the  body  of  such  a  foetus  be  examined,  the  liver 
and  spleen  are  found  enlarged,  perhaps  containing  gummata. 
The  lungs  are  the  seat  of  a  fibroid  pneumonia ;  the  bones  exhibit 
a  reddish-yellow  streak  just  above  the  epiphyses  (Fig.  128),  which 
is  caused  by  the  proliferation  and  fatty  degeneration  of  syphilitic, 


DISEASES    OF   THE    NEW-BORN    CHILD. 


283 


cellular  tissue.     The  nostrils  of  such  a  foetus  are  thick ;  its  limbs 
poorly  developed  ;  its  tissues  ill- nourished. 

The  rhachitic  foetus  has  the  projecting  forehead,  the  enlarged 
epiphyses  of  the  long  bones,  the  "beads"  along  the  ribs  where 

FIG.  128. 


FCETAL  BONE,  SYPHILIS,  SHOWING  SYPHILITIC  LINE. 


they  join  the  sternum,  the  projecting  sternum  and  spinal  curva- 
ture which  so  often  mark  this  disease. 

Syphilis  may  be  treated  by  calomel,  gr.  ^,  with  soda ;  by 
inunction  of  mercurial  ointment  or  the  hypodermic  injection  of 
bichloride  of  mercury,  yfo  of  a  grain  in  solution.  Syphilitic 
eruptions  and  sores  may  be  dusted  with  calomel.  Cod-liver  oil 
is  indicated  in  both  syphilis  and  rickets. 


APPENDIX. 


THE  following  memoranda  and  formulae  have  been  found  of 
practical  interest  and  value : 

ANTISEPTICS. — Bichloride  of  mercury  is  best  used  for  cleansing 
the  hands  of  the  obstetrician  and  the  external  genitals  of  the 
patient.  It  has  caused  poisoning  in  vaginal  douches,  i  to  5000. 
It  should  not  be  employed  for  intra-uterine  douches,  as  fatal 
poisoning  may  readily  follow  such  use.  Bichloride  is  usually  sold 
in  tablets.  When  these  cannot  be  obtained,  the  following  pow- 
ders will  be  found  convenient : 

Bichloride  of  mercury grs.  10 

Tartaric  acid grs.  49 

Cochineal gr.      i 

One  powder  dissolved  in  one  pint  of  water  makes  a  solution, 
i  to  1000.  When  a  solution  of  bichloride  is  turbid,  common 
salt  may  be  added  to  favor  complete  solution.  In  strength  of  i 
to  2000  it  may  be  used  for  cleansing  the  hands  and  external 
parts;  in  i  to  5000  to  i  in  10.000  for  vaginal  douches.  Bichlo- 
ride solution,  i  to  1000,  is  useful  to  cleanse  rubber  articles.  Symp- 
toms of  bichloride  poisoning  are  salivation,  sore  teeth  and  gums, 
mucous,  bloody  diarrhoea,  rapid  pulse,  prostration,  coma,  death. 
Treatment  consists  in  stopping  the  use  of  the  bichloride,  using  a 
mouth  wash  of  equal  parts  of  potassium  chlorate  and  boracic  acid 
in  solution,  and  giving  opium  and  stimulants  for  the  diarrhoea. 

CARBOLIC  ACID  AND  CREOLIN  are  valuable  in  2  per  cent,  so- 
lutions for  intra-uterine  douches  and  to  cleanse  metal  instruments. 
Glycerine  should  be  added  to  carbolic  solutions  to  insure  solu- 
284 


APPENDIX.  285 

bility.  Creolin  forms  a  ready  emulsion  with  water.  In  30  drops 
to  the  pint  of  warm  water  it  makes  an  excellent  vesical  douche  in 
cystitis.  Its  odor  is  disagreeable  to  many  ;  it  stains  linen  and 
white  rubber  articles ;  it  is  very  irritating  to  the  skin  of  some 
patients.  Severe  pain  is  sometimes  complained  of  after  the  use 
of  creolin  solutions  2  per  cent.,  but  inflammation  rarely  follows  in 
these  cases. 

Carbolic  acid  and  creolin  cause  smoky  urine  in  cases  of  poison- 
ing, with  dysuria  and  toxaemia,  terminating  in  coma  and  death. 
Aside  from  stopping  the  use  of  the  poisonous  substance,  but  little 
can  be  done  in  treating  these  cases. 

BORACIC  ACID  is  an  excellent  antiseptic  for  use  on  the  mother's 
nipple,  in  the  child's  mouth  and  eyes,  and  in  6o-grain  supposi- 
tories within  the  uterus.  Saturated  solutions  may  be  used,  with 
the  addition  of  5^2  of  glycerine  to  the  ^.  In  powder,  boracic 
acid  is  useful  as  a  dressing  for  the  umbilicus,  and  in  dusting  the 
folds  of  the  skin  in  children  disposed  to  eczema. 

THYMOL,  i  to  1,000,  is  an  excellent  intra-uterine  douche. 

IODOFORM  may  be  used  in  suppositories  within  the  uterus  in  the 
following  formula : 

lodoform grs.  300 

Gum  Arabic. 

Glycerine 

Starch ;    .    .  aa  gr.  30 

In  3  suppositories,  or  the  quantity  of  iodoform  may  be  grs.  180, 
each  suppository  containing  60  grains. 

lodoform  may  be  used  to  dust  the  umbilicus  and  cord  ;  it  may 
be  combined  with  bismuth  subnitrate,  equal  parts. 

DRESSINGS  FOR  THE  UMBILICAL  CORD. — Powdered  salicylic 
acid,  i  part ;  powdered  starch,  5  parts ;  powdered  boracic  acid  ; 
iodoform  and  bismuth  equal  parts. 

A  mass  of  absorbent  cotton  large  enough  to  receive  the  cord 
and  cover  it,  is  sprinkled  freely  with  one  of  the  above  powders  ; 
the  cord  is  enfolded  in  the  cotton,  turned  upwards  and  to  the 
left  of  the  umbilicus  and  the  belly-band  pinned  over  it. 


286  APPENDIX. 

The  following  OINTMENT  will  be  found  useful  in  healing  SORE 
NIPPLES : 

Powdered  boracic  acid grs.  10 

Cold  cream ^i 

Or 

Powdered  boracic  acid grs.  10 

Lanolin 

Cosmoline aa  5^ 

Or  powdered  zinc  oxide  or  bismuth  subnitrate  in  the  same  pro- 
portion, with  these  bases. 

DIRECTION  FOR  MAKING  A  BREAST-BINDER  OR  COMPRESSION 
BANDAGE. — It  is  twenty-nine  inches  long  by  eight  wide ;  three 
and  a  half  inches  from  either  extremity,  and  in  the  centre  of  the 
bandage  two  holes  have  been  cut  the  size  of  a  quarter  of  a  dollar, 
the  edges  of  which  are  carefully  overseamed  to  prevent  the  aper- 
tures from  tearing  out,  the  distance  between  them  being  the  dis- 
tance measured  between  the  nipples.  At  the  upper  edge  of  the 
bandage,  five  inches  from  the  end,  two  shoulder-straps  are  at- 
tached, two  inches  wide.  The  bandage  is  so  applied  that  it  pins 
over  the  centre  of  the  chest  between  the  breasts,  the  apertures 
giving  room  for  the  nipples,  through  which  the  child  may  nurse. 
The  shoulder-straps  come  over  the  shoulders  and  may  cross  in 
front,  or  be  pinned  without  crossing,  to  the  upper  edge  of  the 
bandage  after  it  has  been  fastened  about  the  body.  The  pur- 
pose of  this  bandage  is  to  draw  the  breasts  upward  and  inward, 
thus  relieving  the  pain  caused  by  engorgement.  This  bandage 
may  be  made  of  Canton  flannel  or  of  firm  muslin  as  desired. 

THE  ABDOMINAL  BINDER. — A  strip  of  hemmed  muslin  12 
inches  wide,  from  24  to  30  inches  long. 

LAXATIVES. — For  use  during  pregnancy  the  compound  licorice 
powder  is  excellent;  also  the  compound  rhubarb  pill  of  the 
U.  S.  P.  Women  threatened  with  eclampsia  do  well  with  the 
compound  colocynth  pill. 


APPENDIX.  287 

After  labor  Fordyce  Barker's  post  partum  pill  is  useful : 

Ext.  coldcynth  comp gr.  20 

Ext.  hyoscyam gr.  15 

Pulv.  aloes  socot gr.  10 

Ext.  nucis  vom gr.    5 

Podophyllin 

Ipecacuanha aa gr.    i 

In  1 2  pills.     Two  may  be  taken  at  a  dose. 

If  the  tongue  be  furred  and  coated,  calomel,  grs.  2^,  and 
sodium  bicarbonate,  gr.  10,  may  be  taken,  followed  in  eight  or 
ten  hours  by  a  seidlitz  powder  and  a  copious  rectal  injection. 

ANAESTHETICS  are  to  be  chosen  in  obstetric  cases  as  follows  : — 

Chloroform,  in  normal  labor  as  an  anodyne  until  the  moment 
of  delivery,  when  complete  anaesthesia  is  desired.  In  threatened 
uterine  rupture,  where  uterine  tetanus  is  present,  chloroform  to 
complete  anaesthesia  is  indicated.  To  relax  a  tightly  contracted 
uterus  to  permit  the  removal  of  a  retained  placenta,  chloroform 
is  indicated ;  for  the  low  forceps  operation  and  for  version. 

Ether  is  to  be  preferred  for  Csesarean  section ;  amputation  of 
the  uterus  ;  craniotomy ;  the  high  forceps  application ;  for  sutur- 
ing the  perineum. 

Bromide  of  ethyl  and  the  alcohol,  chloroform  and  ether  mix- 
ture, alcohol  i,  chloroform  2,  ether  3,  have  been  used,  but  pos- 
sesses no  practical  advantages  over  ether  and  chloroform. 

THE  DIAGNOSIS  OF  CONTRACTED  PELVIS. — The  following 
measurements  are  to  be  made  : 

Between  the  ant.  sup.  spines  of  the  ilia. 

Between  the  crests  of  the  ilia. 

The  external  conjugate,  from  beneath  the  spine  of  the  last 
lumbar  vertebra  to  the  pubic  joint,  anterior  aspect. 

The  internal,  true  conjugate,  from  the  sacral  promontory  to  the 
posterior  surface  of  the  pubic  joint. 

Between  the  tuberosities  of  the  ischia. 

From  the  post.  sup.  spine  of  the  ilium  of  one  side  to  the  ant. 
sup.  spine  of  the  other. 


288  APPENDIX. 

The  following  clinical  data  are  given  by  Diihrssen,  as  indicating 
the  presence  of  pelvic  deformity  : 

Small  stature. 

Curved  and  prominent  extremities. 

Pendulous  abdomen  during  a  first  pregnancy. 

History  of  previous  difficult  labor. 

Complicated  labor. 

Premature  rupture  of  the  membranes. 

Prolapse  of  the  cord  or  foetal  limbs. 

Failure  of  the  head  to  enter  the  pelvis. 

Abnormal  position  and  presentation  of  the  child. 

The  various  presentations  of  the  head  in  contracted  pelves  are  : 
In  flat  pelvis,  the  anterior  fontanelle  sinks  deeply,  a  parietal  bone 
presenting ;  in  symmetrically-contracted  pelves,  the  posterior  fon- 
tanelle and  vertex  sink  deeply ;  in  flat,  rhachitic  pelves,  present- 
ation of  parietal  bone  and  deep  position  of  the  smaller  fonta- 
nelle. These  various  positions  are  those  most  favorable  in  the 
respective  kinds  of  contracted  pelves. 

CONTENTS  OF  BABY  BASKET. — This  basket  should  include  the 
baby's  toilet  articles :  simple  rice  powder,  a  little  pot  of  white 
vaseline  or  cold  cream,  white  Castile  or  spermaceti  soap,  and 
such  other  articles  as  an  experienced  nurse  or  mother  may  deem 
necessary.  We  append  a  list  of  an  outfit  which  has  been  found 
of  practical  use :  brush  and  comb ;  skein  of  white  twisted  em- 
broidery silk ;  soft  fine  sponge ;  bottle  of  white  vaseline ;  sharp 
pair  of  pointed  scissors;  powder-box  and  puff,  with  talc  powder; 
pin-cushion  ;  small  and  large  safety-pins;  pure  castile  soap;  pair 
of  socks ;  some  old,  fine  linen  ;  flannel  or  knitted  band  ;  flannel 
shirt,  a  petticoat  and  night-gown  for  infant ;  an  afghan  or  piece 
of  extra  flannel,  in  which  to  wrap  child  ;  also  piece  of  flannel,  or 
old  blanket,  to  receive  it  in ;  in  addition  the  baby  will  require 
eight  day  dresses,  eight  night  gowns,  eight  white  skirts,  four  day 
flannel  skirts,  four  night  flannel  skirts,  four  pairs  of  day  socks, 
four  pairs  of  night  socks,  six  flannel  shirts,  six  flannel  bands, 
three  dozen  small  soft  linen  diapers,  three  dozen  larger  cotton 
ones,  at  least  two  little  knitted  sacques. 


APPENDIX.  289 

The  following  description  of  A  CROCHETTED  BABY-BAND  is  taken 
from  "Babyhood,"  Vol.  III.,  p.  33:  "Single  zephyr  in  ridge 
stitch ;  that  is,  half  stitch,  in  which,  going  back  and  forth,  only 
the  back  half  of  the  stitches  in  the  lower  row  are  picked  up. 
Begin  on  a  chain  of  fifty  and  crochet  forty-eight  ridges,  hence 
ninety-six  rows.  Join  by  a  row  of  plain  stitches,  and  at  top  by 
a  picot  edging  (five  chains  and  a  tight  stitch  back  into  the 
first)." 

INFANTILE  COLIC. — Prevented  by  proper  diet  of  mother  and 
systematic  nursing  of  infant. 

Relieved  by  peppermint  water,  gtt.  x-xv,  in  a  little  sweetened 
hot  water.  If  constipation  exists,  it  can  usually  be  relieved  by 
Sodii  Phosphas,  gr.  v-x,  three  times  daily,  given  in  hot  water. 

A  spice  plaster,  or  hot  flannel  over  the  abdomen,  is  also  useful. 

13 


INDEX. 


Page  Page 

A  BDOMINAL  binder 286        Application  of  the  forceps 94 

Abnormal   condition   of  mother's                Area  germinativa 14 

milk 214        Artificial  feeding  of  infants 217 

Abnormal  insertion  of  the  placenta.  .   .  222        Asphyxia 279 

Abnormal  labor,  treatment  of,  in  head-  Asphyxiated  child,  resuscitation  of  .   .  114 

presentation 88        Attitude  of  the  feetus 57 

Abnormalities  of  labor  in  head-presenta-                Auto-transfusion 227 

tions 71        Axial  groove 14 

Abnormalities  of  the  umbilical  cord  .   .  270        Axis  of  the  birth -canal 38 

Abortion 149       Axis-traction 98 

Abortion,  criminal 155 

Abortion,  habit  of 151  T)  ABY-BASKET,  contents  of .   ...  288 

Abortion,  therapeutic 155            '     Bandage,  compression 286 

Accidents    of    labor    endangering     the                Band),  contraction-ring  of 238 

mother 238        Basket,  baby,  contents  of 288 

Acid,  boracic 285        Binder,  abdominal 286 

Acid,  carbolic 284        Binder,  breast 286 

Acute  infections  during  pregnancy     .    .  175        Birth,  foetus  at      29 

Adherence  of  the  placenta  and   mem-                Birth-canal 34 

branes 267        Birth-canal,  axis  of 38 

Adherent  placenta 154  Birth-canal,  disproportion  between   the 

Adhesion  of  the  amnion 269            child  and 133 

Affections  of  the  genito-urinary  organs                Blastodermic  vesicle 13 

during  pregnancy 179        Blood  of  the  new-born  child 282 

After  birth 18  Blood,  the  mother's,  during  pregnancy  184 

Allantois 16        Blood-system,  foetal 21 

Amnial  liquid 16        Bony  pelvis,  dinmeters  of 34 

Amnion 15        Boracic  acid 285 

Amnion,  adhesion  of 269  Braxton- Hicks,  method  of  version  of.  .  124 

Amputation  of  the  pregnant  uterus  .   .  192        Breast,  engorgement  of 261 

Anaemia  of  pregnancy 54        Breast-binder 286 

Anaesthesia  during  labor 79  Breasts,  care  of  during  the  puerperium  .  212 

Anaesthetics 287        Breech-presentation,  first 109 

Anterior  displacement  of  the  pregnant  Breech-presentation,  forceps  in   .   .       .107 

uterus 181         Breech-presentation,  labor  in 109 

Anterior  fontanelle 30  Breech-presentations,     morbidity     and 

Antisepsis  in  labor 87            mortality  of "9 

Antiseptics 284  Breech-presentations,    treatment  of.   .  in 

Appendages,  foetal,  disorders  of     ...  269        Bregma 3° 

29I 


292  INDEX. 

Page  Page 

Brim,  pelvic 35        Contraction-ring  of  Bandl 238 

Brow-presentation 72  Cord,  umbilical  (see  Umbilical  Cord)  .  .      22 

Brow-presentation,  treatment  of .   ...      90        Cotyledons 21 

Cranioclasis 198 

/—jESAREAN  SECTION 188        Craniotomy 194 

Canal,  neural 14  Crede's  method  of  delivery  of  the   pla- 

Caput  succedaneum 66  centa 266 

Carbolic  acid 284        Creolin 284 

Carcinoma  complicating  labor 136        Criminal  abortion 155 

Cardiac  disorders  during  pregnancy  .    .    177 

Care  of  the  breasts  during  the  puerpe-  FA  ANGERS  attending  the  use  of  the 

rium 212  forceps 193 

Care  of  the  umbilical  cord  after  labor ..      87        Death,  foetal,  in  utero 277 

Central  placenta  praevia  • 222        Death,  sudden,  during  labor 248 

Cephalhaematoma .    282        Decapitation 201 

Cephalotribe .   .    196        Decidua,  ovular 13 

Cephalotripsy 199        Decidua,  placental 13 

Cervix  uteri,  laceration  of 243         Decidua  reflexa 13 

Changes   in  the  mother  occasioned  by  Decidua  serotina 13 

pregnancy 43        Decidua,  uterine 13 

Changes   in   the  nervous  system  during  Decidua  vera 13 

pregnancy 182        Decidual  endometritis 269 

Changes  in  the  ovum  after  fecundation  .      12        Deciduous  membranes 12 

Checking  lactation 263  Deficiency  of  fcetal  development  .  ...    273 

Child,  asphyxiated,  resuscitation  of  .    .    114        Deformed  pelvis,  labor  in 139 

Child,  delivery  of 80  Deformities,  spinal,  complicating  labor  146 

Child,  disproportion  between,  and    the  Degeneration,  myxomatous,  of  the  pla- 

birth-canal 132  centa 270 

Child,  new-born,  diseases  of 279  Delayed  labor,  minor  o'.  stetric  surgery 

Child,  new-born,  septic  infection  in  ...    280  in 204 

Child,  new-born,  the  blood  of 282        Delivery,  obstacles  to 135 

Children,  ill-developed 273        Delivery  of  the  child 80 

Chorion 15  Delivery  of  the  placenta,  Crede's  method 

Circular  sinus 20  of 266 

Circulation,  fcetal 26  Development,  excessive,  of  the  foetus.  .    273 

Circulation,  placental 26  Development,  foetal,  deficiency  of .   .    .    273 

Circulation,  vitelline 26        Diagnosis  of  contracted  pelvis 28', 

Cleavage 12  Diagnosis   of  extra-uterine   or    ectopic 

Coils  of  the  umbilical  cord 270  pregnancy 230 

Colic,  infantile 289        Diagnosis  of  labor 61 

Combined  version 124        Diagnosis  of  pregnancy 45 

Complicated  labor,  surgical  treatment  of  188        Diameters  of  the  bony  pelvis 34 

Complications  of  the  puerperal  state  .    .    261         Diameters  of  the  foetal  head 31 

Compression  bandage 286        Diameters  of  the  fcetal  trunk 29 

Compression  of  the  foetal  limbs  ....    269  Diseases  of  the  new-born  child   ....    279 

Conception 9  Disinfection  of  the  cavity  of  the  uterus.    255 

Condition,  abnormal,  of  mother's  milk  .    214  Disorders,  cardiac,  during  pregnancy  .    177 

Constitutional    treatment    of   puerperal  Disorders  of  the  foetal  appendages     .   .    269 

sepsis 258        Disorders  of  the  foetus 273 

Contents  of  baby-basket 288  Disorders  of  the  skin  during  pregnan- 

Contracted  pelvis,  diagnosis  of 287  cy 185 


INDEX. 


293 


Page 


Page 


Displacement,  anterior,  of  the  pregnant               Floor,  pelvic 40 

uterus 181        Foetal  appendages,  disorders  of  ....  269 

Disproportion  between   the  child   and  Foetal  blood-system .21 

the  birth-canal 132        Foetal  body,  Tumors  of 274 

Disturbance,  emotional,  in  the  puerpe-  Foetal  circulation     .  .26 

ral  patient 264        Foetal  limbs,  compression  of 269 

Dressings  for  the  umbilical  cord  .   .   .    285        Foetal  death  in  utero 277 

Drugs,  excretion  of,  in  mother's  milk   .    216        Foetal  development,  deficiency  of .   .   .  273 

Duration  of  pregnancy 60        Fojtal  head 30 

Foetal  trunk 29 

pCLAMPSIA 166        Foetus 24 

•*  Eclampsia,  treatment  of 168        Foetus  at  birth 29 

Ectopic  pregnancy 11,45,228  Foetus,  attitude  and  location  of .   ...  57 

Embryo • 15,  24  Foetus,   disorders   of 273 

Embryology 24  Foetus,  excessive  development  of  ...  273 

Embryotomy ^94  Foetus,  hydrocephalus  in 274 

Emotional  disturbance  in  the  puerperal  Foetus,  impaction  of,  in  labor 76 

patient 264  Foetus,  macerated 278 

Endometritis,  decidual 269  Foetus,  mummified 278 

Engagement  of  the  head  in  the  pelvis  .    133  Foetus,  nourishment  of 26 

Engorgement  of  the  breast 261  Foetus,  position  of 57 

Entopic  pregnancy n  Foetus,  presentation  of •  .   .  57 

Epiblast 12  Foetus,   rhachitis   of 283 

Episiotomy 42,  82  Foetus,  syphilis  of 282 

Evisceration 203  Fontanelle,  anterior 30 

Excessive  development  of  the  foetus  .   .    273  Fontanelle,  posterior 30 

Excretion  of  drugs  in  mothers'  milk  .   .    216  Footlingcase 113 

Expulsion  of  the  placenta 83  Forceps 91 

External  version 124  Forceps,  application  of 94 

Extra-uterine  pregnancy  .   .   .   .11,  45,  228  Forceps,  axis-traction 98 

Extra-uterine  pregnancy,  diagnosis  of  .    230  Forceps,  dangers  attending  the  use  of  .  93 

Forceps  in  breech-presentations  ....  107 

T7  ACE-PRESENTATION 72  Forceps  in  face-presentations 107 

Face-presentation,  first 74  Forceps  in  posterior  rotation  of  the  occi- 

Face-presentation,  forceps  in 107            put 106 

Face-presentation,  mechanism  of  labor  Forceps,  indications  for  the  use  of ...  92 

in .• 74  Forceps,  morbidity  and  mortality  caused 

Face-presentation,  treatment  of ....     90           by '"7 

Faecal  toxaemia 264  Forceps  operation,  high 103 

Fallopian  tubes     .   .   .    .  • n  Forceps,  traction   with 95 

Fecundation,  changes  in  the  ovum  after,     12  Fronto-anterior  position 72 

Feeding,  artificial,  of  infants 217  Fronto-anterior  position,  left 74 

Fever,  puerperal 251  Funnel  shaped  pelvis 147 

Fibroids  complicating  labor 135  ^j^iTO-URINARY  organs,  affec- 

First  breech-presentation 109  ^    tions  of(  during  pregnancy  .  ...  ,79 

First  face-presentation 74  GroovC)  axial  or  meduUary ,4 

First  position 66 

First  stage  of  labor 61  TT  ABIT  of  abortion 15 

First  stage  of  labor,  treatment  of   ...      77  •"     Haemorrhage  from  the  umbilicus  282 

Fissure  of  the  nipples 263  Haemorrhage,   post-partum 233 

Flat  pelvis,  simple 140  Heemorrhage,  uterine 9 


294 


INDEX. 


Page 

Head,  engagement  of,  in  the  pelvis  .    .  133 

Head,  foetal 30 

Head,  impaction  of,  in  labor 72 

Head-presentations,  abnormalities  of  la- 
bor in 71 

Head-presentations,  mechanism  of  la- 
bor in 62 

Head-presentations,  treatment  of  ab- 
normal labor  in 88 

Hegar's  sign  of  pregnancy 52 

Hernia  of  the  pregnant  uterus 186 

High  forceps  operation 103 

Hydrocephalus  in   the  foetus 274 

Hygiene  of  pregnancy 53 

Hypoblast 12 

T  LL-DEVELOPED  children  ....  273 

Impaction  of  the  foetus  in  labor  .    .  76 

Impaction  of  the  head  in  labor  ....  72 

Impregnation n 

Indications  for  the  use  of  the  forceps  .  92 

Induced  labor 157 

Infantile  colic 289 

Infantile  pelvis ....  147 

Infants,  artificial  feeding  of 217 

Infections,  acute,  during  pregnancy  .   .  175 

Injuries  to  the  pelvic  floor 41 

Insanity  during  pregnancy 183 

Insertion,  abnormal,  of  the  placenta  .  222 

Internal  version 124 

Interstitial   pregnancy 230 

Intra-uterine   pregnancy n 

Inversion  of  the  uterus 242 

Involution 206 

lodoform 285 

JAUNDICE  during  pregnancy     .   .    .  185 

Jelly,  Whaiton's 22 

Joints,  pelvic,  relaxation  of,  during  preg- 
nancy    182 

Jtisto  major  pelvis 139 

Justo-minor  pelvis 139 

T   ABOR 61 

*"*  Labor,  abnormal,  treatment  of,  in 

head-presentation 88 

Labor,  abnormalities  of,  in  head-presen- 
tations    71 

Labor,  accidents  of,  endangering  the 

mother 238 

Labor,  anaesthesia  during 79 


Page 

Labor,  antisepsis  in 87 

Labor,  carcinoma  complicating  ....  136 

Labor,  care  of  the  umbilical  cord  after  87 

Labor,  complicated,  surgical  treatment  of  188 
Labor,  delayed,  minor  obstetric  surgery 

in 204 

Labor,  diagnosis  of                61 

Labor,  fibroids  complicating 135 

Labor,  first  stage  of 61 

Labor,  impaction  of  the  ioetus  in   ...  76 

Labor,  impaction  of  the  head  in     ...  72 

Labor  in  breech-presenta'ion 109 

Labor  in  deformed  pelvis 139 

Labor,  induced 157 

Labor  in  multiple  pregnancies     ....  163 

Labor  in  symmetrically-large  pelves  .   .  139 

Labor  in  symmetrically-small  pelves     .  139 

Labor  in  transverse  positions 120 

Labor,  malformations  complicating       .  137 
Labor,  mechanism  of,  in  face-presenta- 
tions       74 

Labor,  mechanism  of,  in  head-presenta- 
tions       62 

Labor,  ovarian  cysts  complicating     .   .  137 

Labor,  premature 149 

Labor,  rupture  of  the  pubic  joint  during  249 

Labor,  second  stage  of 69 

Labor,  spinal  deformities  complicating  146 

Labor,  sudden  death  during 248 

Labor,  support  of  the  perineum  in     .    .  80 

Labor,  third  stage  of 83 

Labor,  thrombosis  of  the  veins  about  the 

vulva  and  vagina  during 249 

Labor,  treatment  of  the  first  stage  of    .  77 

Laceration  of  the  cervix  uteri     ....  243 

Laceration  of  the  pelvic  floor 85 

Laceration  of  the  perineum  and  pelvic 

floor 245 

Lactation 212 

Lactation,  checking 263 

Large  pelves,  symmetrically,  labor  in   .  139 

Lateral  placenta  prsevia 223 

Laxatives 286 

Left  fronto-anterior  position 74 

Left  occipito-anterior  position     ....  66 

Litigation  of  the  umbilical  cord  ....  81 

Limbs,  foetal,  compression  of 269 

Liquor  amnii 16 

Ljthopaedion 278 

Location  of  the  foetus 57 

Lying-in  period 206 


INDEX. 


295 


Page 

TV /TACERATED  foetus 278 

Malformations  complicating  labor  137 

Marginal  placenta  praevia 222 

Mask  of  pregnancy 185 

Mastitis 262 

Measurements,  pelvic 46 

Mechanism  of  labor  in  face-presentation     74 
Mechanism  of  labor  in  head-presenta- 
tions           62 

Meconium 29 

Medullary  groove 14 

Membrane,  vitelline 18 

Membrane,  yelk 15 

Membranes,  deciduous 12 

Membranes,  placenta  and,  adherence  of  267 

Menstruation 9 

Mento-anterior  position 72 

Mento-posterior  position,  right   ....      74 

Mesoblast 13 

Milk,  mothers',  abnormal  condition  of  .  204 
Milk,  mothers',  excretion  of  drugs  in  .  216 
Milk,  mothers',  substitutes  for  ....  318 

Milk,  sterilization  of 219 

Minor  obstetric  surgery  in  delayed  labor  204 

Miscarriage '49 

Mole,  vesicular 37° 

Monsters 277 

Morbidity  and  mortality  caused  by  the 

forceps 107 

Morbidity  and  mortality  of  breech-pres- 
entations      "9 

Mother,  accidents  of  labor  endangering  238 

Mother-cake "8 

Mother  in  pregnancy 43 

Mother's  blood  during  pregnancy  ...  184 
Mothers'  milk,  abnormal  condition  of  .  214 
Mothers'  milk,  excretion  of  drugs  in  .  .  216 

Mothers'  milk,  substitutes  for 218 

Multiple  pregnancy IDI 

Multiple  pregnancy,  labor  in 163 

Mummified  foetus *7S 

Muriform  body I2 

Myxomatous  degeneration  of   the  pla- 
centa     2/0 

TVJ  AUSEA  and  vomiting  of  pregnancy  53 
•*•  Nephritis  during  pregnancy  .  .  .  173 
Nervous  system,  changes  in,  dwingpreg- 

nancy l8a 

Neural  canal '  4 

New-born  child,  diseases  of 279 


Page 

New-born  child,  septic  infection  in  ...  280 

New-born  child,  the  blood  of 282 

Nipples,  fissure  of 263 

Nipples,  sore 286 

Nodes  of  the  umbilical  cord 23 

Normal  pregnancy n 

Nourishment  of  the  foetus  .   .          ...  26 


•47 


/^vBLIQUELY-CONTRACTED  pel- 


Obstacles  to  delivery 135 

Obstetric   surgery,    minor,    in    delayed 

labor 804 

Obstetric  trephines      197 

Occipito-anterior  position,  left  ....  66 

Occipito  posterior  position 71 

Occipito-sacral  position,  treatment  of .  90 
Occiput,  posterior  rotation  of,  forceps 

in 

Operation,  high  forceps 103 

Ophthalmia  neonatorum 280 

Osteomalacic  pelvis 14? 

Osteoporosis '48 

Osteosclerosis '48 

Outlet,  pelvic 37 

Ova I0 

Ovarian  cysts  complicating  labor   ...  1 37 

Ovarian  pregnancy 230 

Ovaries IO 

Oviducts Il 

Ovum,  changes  in  the/after  fecundation  12 

Ovular  decidua '3 

Ovulation 9 


pARAMETRITIS 254 

Parietal-bone  presentation  ....  72 

Partial  placenta  przvia 222 

Pathology  of  pregnancy »66 

Pelves,  deformed  labor  in, 139 

Pelves,  symmetrically  small,  labor  in   .  139 

Pelvic  brim 35 

Pelvic  floor -»° 

Pelvic  floor,  injuries  to 4« 

Pelvic  floor,  laceration  of 85 

Pelvic  floor,  laceration  of  the  perineum 

and 245 

Pelvic  joints,  relaxation  of,  during  preg- 

182 

46 

37 


nancy   

Pelvic  measurements 
Pelvic  outlet  .... 


296 


INDEX. 


Page  Page 

Pelvimeter 51  Pregnancy,    affections    of    the    genito- 

Pelvis,  contracted,  diagnosis  of  ....  287            urinary  organs  during 179 

Pelvis,  engagement  of  the  head  in  .    .    .  133        Pregnancy,  anaemia  of 54 

Pelvis,  funnel-shaped 147  Pregnancy,  cardiac  disorders  during  .   .  177 

Pelvis,  infantile 147  Pregnancy,  changes  in  the  nervous  sys- 

Pelvis  justo-major 139            tern  during 182 

Pelvis  justo-minor 139  Pregnancy      complicated     by      foreign 

Pelvis,  obliquely-contracted 147  growths  in  the  uterus  and  pelvis  .    .   .  187 

Pelvis,  osteo-malacic 147        Pregnancy,  diagnosis  of 45 

Pelvis,  pregnancy  complicated  by  foreign  Pregnancy,  disorders  of  the  skin  during  185 

growths  in  the  uterus  and 187        Pregnancy,  duration  of 60 

Pelvis,  rhachitic 143        Pregnancy,  ectopic n,  45,  228 

Pelvis,  simple  flat 140  Pregnancy,  ectopic,  diagnosis  of ..    .    .  230 

Pelvis,  symmetrically-large,  labor  in  .   .  139        Pregnancy,  entopic n 

Pelvis,  symmetrically-imall,  labor  in  .   .  139  Pregnancy,  extra-uterine    .    .    .    .11,45,228 

Perimetritis 254  Pregnancy,  extra-uterine,  diagnosis  of .  230 

Perineum  and  pelvic  floor,  laceration  of  245        Pregnancy,  Hegar's  sign  of 52 

Perineum,  support  of,  in  labor 80        Pregnancy,  hygiene  of 53 

Period,  lying-in 206        Pregnancy,  insanity  during 183 

Pernicious  vomiting  of  pregnancy  .   .    .  184        Pregnancy,  interstitial 230 

Placenta 16,  18        Pregnancy,  intra-uterine •     .  n 

Placenta,  abnormal  insertion  of.    ...  222        Pregnancy,  jaundice  during 185 

Placenta,  adherent 154        Pregnancy,  mask  of 185 

Placenta  and  membranes,  adherence  of  267        Pregnancy,  mother  in •     .    .  43 

Placenta,  delivery  of,  Crede's  method  of  266  Pregnancy,  mother's  blood  during     .    .  184 

Placenta,  expulsion  of 83        Pregnancy,  multiple 161 

Placenta,  myxomatous  degeneration  of  270  Pregnancy,  nausea  and  vomiting  of,  .    .  53 

Placenta  praevia 222        Pregnancy,  nephritis  during 173 

centralis 222        Pregnancy,  normal n 

lateralis 222        Pregnancy,  ovarian 230 

marginalis 222        Pregnancy,  pathology  of 166 

partialis 222  Pregnancy,  pernicious  vomiting  of    .   .  184 

Placenta,  retention  of 267  Pregnancy,    relaxation     of   the    pelvic 

Placenta  succenturiata 22            joints  during 182 

Placenta,  syphilis  of 270        Pregnancy,  tubal 228 

Placental  circulation 26  Pregnancy,  varicose  veins  during  .    .    .  186 

Placental  decidua 13  Pregnant  uterus,  amputation  of ....  192 

Polyhydramnios 269  Pregnant  uterus,  anterior  displacement 

Position,  first  or  left  occipito-anterior    .  66            of 181 

Position,  fronto-anterior 72        Pregnant  uterus,  hernia  of 186 

Position,  left  fronto-anterior 74  Pregnant  uterus,  retro-displacement  of  .  180 

Position,  mento-anterior 72        Premature  labor 149 

Position,  occipito-posterior 71         Presentation,  brow 72 

Position  of  the  foetus 57        Presentation,  face •    .   .    .  72 

Position,  right  mento-posterior 74        Presentation  of  the  foetus 57 

Posterior  fontanelle 30        Presentation,  parietal-bone 72 

Posterior  rotation  of  the  occiput,  forceps  Prolapse  of  the  umbilical  cord     ....  271 

in 106  Pubic  joint,  rupture  of,  during  labor     .  249 

Post-partum  haemorrhage 233        Puerperal  fever 251 

Pregnancy 10  Puerperal  patient,  emotional  distance  in  264 

Pregnancy,  acute  infections  during ..    .  175        Puerperal  sepsis 251 


INDEX. 


297 


Page 

Puerperal   sepsis,    constitutional    treat- 
ment of 258 

Puerperal  sepsis,  surgical  treatment  of  .    260 
Puerperal  state,  complications  of    ...    261 

Puerperium 206 

Puerperium,  care  of  the  breasts  during.    212 

•p  ELAXATION   of  the  pelvic  joints 

during  pregnancy 182 

Resuscitation  of  an  asphyxiated  child  .    114 

Retention  of  the  placenta 266 

Retro-displacement  of  the  pregnant  ute- 
rus     180 

Rhachitic  pelvis 143 

Rhachitis  of  the  foetus 283 

Right  memo-posterior  position    ....      74 

Rotation 67 

Rotation   of  the  occiput,  posterior,  for- 
ceps in 106 

Rupture  of  the  pubic  joint  during  labor.  249 
Rupture  of  the  uterus 238 

QECOND  stage  of  labor 69 

v-'     Section,  Csesarean 188 

Segmentation 12 

Selection  of  a  wet-nurse 217 

Sepsis,  puerperal 251 

Septic  infection  in  the  new-born  child   .  280 

Simple  flat  pelvis 140 

Sinus,  circular 20 

Skin,  disorders  of,  during  pregnancy  .  185 

Small  pelvis,  symmetrically,  labor  in  .  139 

Sore  nipples 286 

Spermatozoid n 

Spinal  deformities  complicating  labor  .  146 

Stage  of  labor,  first 61 

Stage  of  labor,  second  .......  69 

Stage  of  labor,  third 83 

Sterilization  of  milk 219 

Strait,  superior 35 

Subinvolution 263 

Substitutes  for  mothers'  milk 218 

Sudden  death  during  labor 248 

Superfecundation 161 

Superfoetation 161 

Superior  strait 35 

Support  of  the  perineum  in  labor  ...  80 
Surgery,    minor    obstetric,    in    delayed 

labor 204 

Surgical  treatment  of  complicated  labor  189 

Surgical  treatment  of  puerperal  sepsis  .  260 


Page 

Sutures  of  the  foetal  head 30 

Symmetrically-large  pelves,  labor  in  .  .  139 
Symmetrically  small  pelves,  labor  in  .  .  139 

Syphilis  of  the  foetus 282 

Syphilis  of  the  placenta 270 

'•THERAPEUTIC  abortion 155 

Third  stage  of  labor 83 

Thrombosis  of  the  veins  about  the  vulva 

and  vagina  daring  labor 249 

Thymol 285 

Toxaemia,  fecal 264 

Traction  with  the  forceps 95 

Transverse  positions,  labor  in  •  .  .  .  .  120 
Transverse  positions,  treatment  of  .  .  .  123 
Treatment,  constitutional,  of  puerperal 

sepsis 258 

Treatment  of  abnormal  labor  in  head- 
presentation  88 

Treatment  of  breech- presentations  .  .  in 
Treatment  of  brow-presentation  ...  90 

Treatment  of  eclampsia        168 

Treatment  of  face-presentation  ....  90 
Treatment  of  occipito-sacral  position  .  90 
Treatment  of  the  first  stage  of  labor  .  77 
Treatment  of  transverse  positions  .  .  .  123 
Treatment,  surgical,  of  puerperal  sepsis  260 

Trephines,  obstetric 197 

Trunk,  foetal 29 

Tubal  pregnancy 238 

Tubes.  Fallopian n 

Tumors  of  the  foetal  body 274 

Twins  .   .  162 


T  TMBlLICALcord 22 

*-'     Umbilical  cord,  abnormalities  of     270 
Umbilical  cord,  care  of,  after  labor  .   .      87 


Umbilica 
Umbilica 
Umbilica 
Umbilica 
Umbil,ca 


cord,  coils  of 290 

cord,  dressings  for 185 

cord,  ligation  of 81 

cord,  nodes  of 23 

cord,  prolapse  of 271 


Umbilical  cord,  velamentous  insertion  of    23 

Umbilical  vesicle 15 

Umbilicus,  haemorrhage  from 282 

Uterine  decidua '3 

Uterine  hzmorrhage 9 

Uterus    and   pelvis,  pregnancy    compli- 
cated by  foreign  growths  in 187 

Uterus,  disinfection  of  the  carity  of  .    .  255 

Uterus,  inversion  of 242 


298 


INDEX. 


Page  Page 

Uterus,  pregnant,  amputation  of  ..   .    .    192  Version,  method  of,  of  Braxton-Hicks  .  124 

Uterus,  pregnant,  anterior  displacement  Vesicle,  blastodermic  .........  13 

of  .................    181  Vesicle,  umbilical  ...........  15 

Uterus,  pregnant  hernia  of   ......    :86  Vesicular  mole  .....    •  .....  270 

Uterus,  pregnant,  retro-displacement  of  180  Villi  .................  18 

Uterus,  rupture  of  ..........    238  Vitelline  circulation  ..........  26 

Vitelline  membrane  ..........  18 

T7AGINA,  vulva  and,  thrombosis   of  Vomiting  of  pregnancy  ........  53 

the  veins  of,  during   labor  ....    249  Vomiting,  pernicious,  of  pregnancy    .    .  184 

Vaginitis  ...............    253  Vulva    and    vagina,  thrombosis   of  the 

Varicose  veins  during  pregnancy  ....    186  '  veins  about,  during  labor  ......  249 

Veins    about     the     vulva    and    vagina,  Vulvitis   ...............  253 

thrombosis  of,  during  labor  .....    249 

Veins,  varicose,  during  pregnancy  .   .    .    186  "I  \  7ET-NURSE,  selection  of  ....  217 

Velamentous   insertion  of  the  umbilical  Wharton's  jelly  ........  22 

''''''''''''''' 


Version,  combined  ..........    124 

Version,  external  ...........    124         yQNA    PELLUCIDA  .......      i? 

Version,  internal  ...........    124        Z^ 


CATALOGUE  No.  7. 


SEPTEMBER,  1891. 


A  CATALOGUE 

OF 

BOOKS  FOR  STUDENTS. 

INCLUDING  THE 

PQUIZ-COMPENDS? 


CONTENTS. 

PAGE 

PAG 

New  Series  of  Manuals,  2,3 

,4.5 

Obstetrics.     . 

Anatomy, 

6 

Pathology,  Histology, 

Biology, 
Chemistry,     . 

ii 
6 

Pharmacy.     . 
Physical  Diagnosis, 

Children's  Diseas* 
Dentistry, 

s, 

I 

Physiology,  . 
Practice  of  Medicine, 

ii 

Dictionaries, 

8 

Prescription  Books, 

Eye  Diseases, 
Electricity,    . 

9 
9 

PQuiz-Compends  ? 
Skin  Diseases, 

M 

Gynaecology, 

10 

Surgery, 

9 
9 

Therapeutics, 
Urine  and  Urinary  Org 

ans, 

Materia  Medica,  . 

Medical  Jurisprudence 

10 

Venereal  Diseases, 

PUBLISHED   BY 


P.  BLAKISTON,  SON  &  CO., 

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ty  Gould's  New  Medical  Dictionary  Just  Ready.     See  page  lO. 


"An  excellent  Series  of  Manuals." — Archives  of  Gynaecology. 

A  NEW  SERIES  OF 

STUDENTS'    MANUALS 

On  the  various  Branches  of  Medicine  and  Surgery. 

Can  be  used  by  Students  of  any  College. 
Price  of  each,  Handsome  Cloth,  $3.00.    Full  Leather,  $3,50. 

The  object  of  this  series  is  to  furnish  good  manuals 
for  the  medical  student,  that  will  strike  the  medium 
between  the  compend  on  one  hand  and  the  prolix  text- 
book on  the  other — to  contain  all  that  is  necessary  for 
the  student,  without  embarrassing  him  with  a  flood  of 
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No.  1.     SURGERY.     236  Illustrations. 
A    Manual   of   the   Practice  of    Surgery.     By  WM.  J. 
WALSHAM,  M.D.,  Asst.  Surg.  to,  and  Demonstrator  of 
Surg.   in,  St.   Bartholomew's  Hospital,   London,  etc. 
236  Illustrations. 

Presents  the  introductory  facts  in  Surgery  in  clear,  precise 
language,  and  contains  all  the  latest  advances  in  Pathology, 
Antiseptics,  etc. 

"  It  aims  to  occupy  a  position  midway  between  the  pretentious 
manual  and  the  cumbersome  System  of  Surgery,  and  its  general 
character  may  be  summed  up  in  one  word — practical." — The  Medi- 
cal Bulletin. 

"  Walsham,  besides  being  an  excellent  surgeon,  is  a  teacher  in 
its  best  sense,  and  having  had  very  great  experience  in  the 
preparation  of  candidates  for  examination,  and  their  subsequent 
professional  career,  may  be  relied  upon  to  have  carried  out  his 
work  successfully.  Without  following  out  in  detail  his  arrange- 
ment, which  is  excellent,  we  can  at  once  say  that  his  book  is  an 
embodiment  of  modern  ideas  neatly  strung  together,  with  an  amount 
of  careful  organization  well  suited  to  the  candidate,  and,  indeed,  to 
the  practitioner." — British  Medical  Journal. 

Price  of  each  Book,  Cloth,  $3.00 ;  Leather,  $3.60. 


THE  NEW  SERIES  OF  MANUALS. 


No.  2.    DISEASES  OP  WOMEN.    15O  Illus. 

NEW     EDITION. 

The  Diseases  of  Women.  Including  Diseases  of  the 
Bladder  and  Urethra.  By  DR.  F.  WINCKEL,  Professor 
of  Gynaecology  and  Director  of  the  Royal  University 
Clinic  for  Women,  in  Munich.  Second  Edition.  Re- 
vised and  Edited  by  Theophilus  Parvin,  M.D., 
Professor  of  Obstetrics  and  Diseases  of  Women  and 
Children  in  Jefferson  Medical  College.  150  Engrav- 
ings, most  of  which  are  original. 
"  The  book  will  be  a  valuable  one  to  physicians,  and  a  safe  and 

satisfactory  one  to  put  into  the  hands  of  students.     It  is  issued  in  a 

neat  and  attractive  form,  and  at  a  very  reasonable  price." — Boston 

Medical  and  Surgical  Journal . 

No.  3.    OBSTETRICS.    227  Illustrations. 
A  Manual  of  Midwifery.     By  ALFRED  LEWIS  GALABIN, 
M.A.,  M.D.,  Obstetric  Physician  and  Lecturer  on  Mid- 
wifery and  the  Diseases  of  Women  at  Guy's  Hospital, 
London;     Examiner  in    Midwifery   to   the   Conjoint 
Examining  Board  of  England,  etc.     With  227  Illus. 
"  This  manual  is  one  we  can  strongly  recommend  to   all   who 
desire  to  study  the  science  as  well  as  the  practice  of  midwifery. 
Students   at  the  present  time  not  only  are  expected  to  know  the 
principles  of  diagnosis,  and  the  treatment  of  the  various  emergen- 
cies and  complications  that  occur  in  the  practice  of  midwifery,  but 
find  that   the   tendency  is   for  examiners  to  ask  more  question* 
relating  to  the  science  of  the  subject  than  was  the  custom  a  few 
years   ago.  *  *  *    The  general  standard  of  the  manual  is  high ; 
and  wherever  the  science  and  practice  of  midwifery  are  well  taught 
it  will  be  regarded  as  one  of  the  most  important  text-books  on  the 
subject." — London  Practitioner. 

No.  4.    PHYSIOLOGY.    Fifth  Edition. 

321  ILLUSTRATIONS  AND  A  GLOSSARY. 
A  Manual  of  Physiology.  By  GERALD  F.  YEO,  M.D., 
F.R.C.s.,  Professor  of  Physiology  in  King's  College, 
London.  321  Illustrations  and  a  Glossary  of  Terms. 
Fifth  American  from  last  English  Edition,  revised  and 
improved.  758  pages. 

This  volume  was  specially  prepared  to  furnish  students  with  a 
new  text-book  of  Physiology,  elementary  so  far  as  to  avoid  theories 
which  have  not  borne  the  test  of  time  and  such  details  of  methods 
as  are  unnecessary  for  students  in  our  medical  colleges. 

"The  brief  examination  I  have  given  it  was  so  favorable  that  I 
placed  it  in  the  list  of  text-books  recommended  in  the  circular  of  the 
University  Medical  College."— Prof.  Ltwit  A.  Stimson,  M.D., 
57  East  33d  Street,  New  York. 

Price  of  each  Book,  Cloth,  $3.00;  Leather,  $3.50. 


THE  NEW  SERIES  OF  MANUALS. 


No.  5.    DISEASES  OF  CHILDREN. 

SECOND  EDITION. 

A  Manual.  By  J.  F.  GOCDHART,  M.D.,  Phys.  to  the 
Evelina  Hospital  for  Children ;  Asst.  Phys.  to 
Guy's  Hospital,  London.  Second  American  Edition. 
Edited  and  Rearranged  by  Louis  STARR,  M.D.,  Clinical 
Prof,  of  Dis.  of  Children  in  the  Hospital  of  the  Univ. 
of  Pennsylvania,  and  Physician  to  the  Children's  Hos- 
pital, Phila.  Containing  many  new  Prescriptions,  a  list 
of  over  50  Formulae,  conforming  to  the  U.  S.  Pharma- 
copoeia, and  Directions  for  making  Artificial  Human 
Milk,  for  the  Artificial  Digestion  of  Milk,  etc.  Illus. 

"  The  merits  of  the  book  are  many.  Aside  from  the  praiseworthy 
work  of  the  printer  and  binder,  which  gives  us  a  print  and  page 
that  delights  the  eye,  there  is  the  added  charm  of  a  style  of  writ- 
ing that  is  not  wearisome,  that  makes  its  statements  clearly  and 
forcibly,  and  that  knows  when  to  stop  when  it  has  said  enough. 
The  insertion  of  typical  temperature  charts  certainly  enhances  the 
value  of  the  book.  It  is  rare,  too,  to  find  in  any  text-book  so  many 
topics  treated  of.  All  the  rarer  and  out-of-the-way  diseases  are 
given  consideration.  This  we  commend.  It  makes  the  work 
valuable." — Archives  of  Pedriatics ,  July ,  1890. 

"  The  author  has  avoided  the  not  uncommon  error  of  writing  a 
book  on  general  medicine  and  labeling  it  '  Diseases  of  Children,' 
but  has  steadily  kept  in  view  the  diseases  which  seemed-  to  be 
incidental  to  childhood,  or  such  points  in  disease  as  appear  to  be  so 
peculiar  to  or  pronounced  in  children  as  to  justify  insistence  upon 
them.  *  *  *  A  safe  and  reliable  guide,  and  in  many  ways 
admirably  adapted  to  the  wants  of  the  student  and  practitioner." — 
American  Journal  of  Medical  Science. 

"  Thoroughly  individual,  original  and  earnest,  the  work  evi- 
dently of  a  close  observer  and  an  independent  thinker,  this  book, 
though  small,  as  a  handbook  or  compendium  is  by  no  means  made 
up  of  bare  outlines  or  standard  facts." — The  Therapeutic  Ga- 
zette. 

"As  it  is  said  of  some  men,  so  it  might  be  said  of  some  books, 
that  they  are  'born  to  greatness.'  This  new  volume  has,  we 
believe,  a  mission,  particularly  in  the  hands  of  the  younger 
members  of  the  profession.  In  these  days  of  prolixity  in  medical 
literature,  it  is  refreshing  to  meet  with  an  author  who  knows  both 
what  to  say  and  when  he  has  said  it.  The  work  of  Dr.  Goodhart 
(admirably  conformed,  by  Dr.  Starr,  to  meet  American  require- 
ments) is  the  nearest  approach  to  clinical  teaching  without  the 
actual  presence  of  clinical  material  that  we  have  yet  seen." — New 
York  nitdical  Record, 

Price  of  each  Book,  Cloth,  $3.00:  Leather,  $3.50. 


THE   NEW  SERIES  OF  MANUALS. 


No.  6.    PRACTICAL  THERAPEUTICS. 

FOURTH  EDITION,  WITH  AN  INDEX  OF  DISEASES. 

Practical  Therapeutics,  considered  with  reference  to 
Articles  of  the  Materia  Medica.  Containing,  also,  an 
Index  of  Diseases,  with  a  list  of  the  Medicines 
applicable  as  Remedies.  By  EDWARD  JOHN  WARING, 
M.D.,  F.R.C.P.  Fourth  Edition.  Rewritten  and  Re- 
vised by  DUDLEY  W.  BUXTON,  M.D.,  Asst.  to  the  Prof, 
of  Medicine  at  University  College  Hospital. 

"  We  wish  a  copy  could  be  put  in  the  hands  of  every  Student  or 
Practitioner  in  the  country.  In  our  estimation,  it  is  the  best  book 
of  the  kind  ever  written.  —JV.  Y.  Medical  Journal . 

"  Dr.  Waring's  Therapeutics  has  long  been  known  as  one  of  the 
most  thorough  and  valuable  of  medical  works.  The  amount  of 
actual  intellectual  labor  it  represents  is  immense.  .  .  .  An  in- 
dex of  diseases,  with  the  remedies  appropriate  for  their  treatment, 
closes  the  volume." — Boston  Medical  and  Surgical  Reporter. 

"  The  plan  of  this  work  is  an  admirable  one,  and  one  well  calcu- 
lated to  meet  the  wants  of  busy  practitioners.  There  is  a  remark- 
able amount  of  information,  accompanied  with  judicious  comments, 
imparted  in  a  concise  yet  agreeable  style." — Medical  Record. 

No.  7.    MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

THIRD  REVISED  EDITION. 

By  JOHN  J.  REESE,  M.D.,  Professor  of  Medical  Jurispru- 
dence and  Toxicology  in  the  University  of  Pennsyl- 
vania ;  President  of  the  Medical  Jurisprudence  Society 
of  Phila. ;  Third  Edition,  Revised  and  Enlarged. 


wiiu  me  profound  impression  that  it  should  be  in  the  hands  of  every 
doctor  and  lawyer.  It  fully  meets  the  wants  of  all  students.  .  .  .  . 
He  has  succeeded  in  admirably  condensing  into  a  handy  volume  all 
the  essential  points."—  Cincinnati  Lancet  and  Clinic. 

"  The  book  before  us  will,  we  think,  be  found  to  answer  the  ex- 
pectations of  the  student  or  practitioner  seeking  a  manual  of  juris- 
prudence, and  the  call  for  a  second  edition  is  a  nattering  testimony 
to  the  value  of  the  author's  present  effort.  The  medical  portion 
of  this  volume  seems  to  be  uniformly  excellent,  leaving  little  for 
adverse  criticism.  The  information  on  the  subject  matter  treat* 
has  been  carefully  compiled,  in  accordance  with  recent  knowledge. 
The  toxicological  portion  appears  specially  excellent.  Of  that  por- 
tion of  the  work  treating  of  the  legal  relations  of  the  practitione 
and  medical  witness,  we  can  express  a  generally  favorable  ver- 
dict."— Physician  and  Surgeon,  Ann  Arbor,  Mich. 

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ANATOMY. 


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CHEMISTRY. 


Ai 
DoMalSn- 

:  rf  AisoTwaot  Speos*  and 
7r-r.;      7  t  Mi  Ml  I.:^TM-      7,:  ^  :  .-: 
.    A< 


&*j*f*3S.5JirS«** 


STUDENTS'  TEXT-ROOKS  AND  MANUALS. 


OumuttTj: 

BJowam'sChrmaistiy,  lao^aaic  aad  Oitaaic,  with  1 
Scream  Editioa,    Staged  aad  Rewrinea.    *St 

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Symonds.  Manual  of  Chemistry  .  far  the  special  «te  of  Me<i3- 
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CoBeges,  by  Prof-  C.  C.  ffaarilfoa     HfcirtT»l»i          Ood>,  x.oo 
Holland.   The  Urine,  Common  Poisons,  and  Milk  Analysis, 
Chemical  and  Microscopical.   For  Laboratory  Use.     Fourth 

i  -  :  --  .  :-:-  i--       :         •.;  OoA,tj» 

Van  Hiys.    Urine  Analysis.    OIK.  Ooth,  2.00 

VToIirs  Applied  Medical  Chemistry.     By  Lawrence  Wolff. 


CHILDREN. 

Goodhart  and  Starr.  The  Diseases  of  Children.  Second 
Edition.  By  J.  F.  Goodhart,  H.D.,  Physiciaa  *•  the  Ertdiaa 
Hospital  far  CaOdtea;  Assiccaat  Physiciaa  to  Gay's  Hospital, 
Loodoo.  Revised  aad  Edited  by  Louis  Starr,  M.O.,  CSsical 
Professor  of  Diseases  ofChfldrea  ia  tie  Hospital  of  the  UaHw- 
siry  of  Peamsylvaaia;  Physiciaa  to  the  ChOdrea's  Hospital, 
Phibtdelnhia.  C"r-";-;-e  snay  Prescriptions  aad  Forambe, 
t^nfi.alag  to  the  U.  S.  Phanaacopoeia,  Kreetioos  far  aukiaf; 
Artificial  Hmaaa  Milk,  far  the  Artificial  D«estioa  of  Mitt,  etc. 
-  .  -  .,  doth,  >oo;  Leather,  3-3- 

H,:-    :        I     ,v,:;;     :       :  .-      :-*--  . 

Prafessor  of  Diseases  of  Childi«.ajiea8i> 
:     .;     -.     ,.      .--  Ocdi,  i-oo; 


8          STUDENTS'  TEXT-BOOKS  AND  MANUALS. 

Children: —  Continued. 

Starr.  Diseases  of  the  Digestive  Organs  in  Infancy  and 
Childhood.  With  chapters  on  the  Investigation  of  Disease, 
and  on  the  General  Management  of  Children.  By  Louis  Starr, 
M.D.,  Clinical  Professor  of  Diseases  of  Children  in  the  Univer- 
sity of  Pennsylvania.  Illus.  Second  Edition.  Cloth,  2.25 

DENTISTRY. 

Fillebrown.    Operative  Dentistry.    330  Illus.          Cloth,  2.50 
Flagg's  Plastics  and  Plastic  Filling.     4th  Ed.         Cloth,  4.00 
Gorgas.     Dental  Medicine.    A  Manual  of  Materia  Medica  and 
Therapeutics.     Fourth  Edition.  Cloth,  3.50 

Harris.  Principles  and  Practice  of  Dentistry.  Including 
Anatomy,  Physiology,  Pathology,  Therapeutics,  Dental  Surgery 
and  Mechanism.  Twelfth  Edition.  Revised  and  enlarged  by 
Professor  Gorgas.  1028  Illustrations.  Cloth,  7.00;  Leather,  8.00 
Richardson's  Mechanical  Dentistry.  Fifth  Edition.  569 
Illustrations.  8vo.  Cloth,  4.50;  Leather,  5.50 

Sewill.     Dental  Surgery.    200  Illustrations.     3d  Ed.   Clo.,  3.00 
Taft's  Operative  Dentistry.    Dental  Students  and  Practitioners. 
Fourth  Edition.     100  Illustrations.        Cloth,  4.25  ;  Leather,  5.00 
Talbot.      Irregularities   of  the   Teeth,  and  their  Treatment. 
Illustrated.     8vo.     Second  Edition.  Cloth,  3.00 

Tomes'  Dental  Anatomy.     Third  Ed.     191  Illus.      Cloth,  4.00 
Tomes'  Dental   Surgery.     3d  Edition.      Revised.      292  Illus. 
772  Pages.  Cloth,  5.00 

Warren.  Compend  of  Dental  Pathology  and  Dental  Medi- 
cine. Illustrated.  Cloth,  i.oo;  Interleaved,  1.25 

DICTIONARIES. 

Gould's  New  Medical  Dictionary.  Containing  the  Definition 
and  Pronunciation  of  all  words  in  Medicine,  with  many  useful 
Tables  etc.  J£  Dark  Leather,  3.25  ;  %  Mor.,  Thumb  Index  4.25 

Harris'  Dictionary  of  Dentistry.  Fifth  Edition.  Completely 
revised  and  brought  up  to  date  by  Prof.  Gorgas. 

Cloth,  5.00;  Leather,  6.00 

Cleaveland's  Pronouncing  Pocket  Medical  Lexicon.  3151 
Edition.  Giving  correct  Pronunciation  and  Definition.  Very 
small  pocket  size.  Cloth,  red  edges  .75  ;  pocket-book  style,  i.oo 

Longley's  Pocket  Dictionary.  The  Student's  Medical  Lexicon, 
giving  Definition  and  Pronunciation  of  all  Terms  used  in  Medi- 
cine, with  an  Appendix  giving  Poisons  and  Their  Antidotes, 
Abbreviations  used  in  Prescriptions,  Metric  Scale  of  Doses,  etc. 
24mo.  Cloth,  i.oo;  pocket-book  style,  1.35 

83~  See  pages  2  to  5  for  list  of  Students'  Manual*. 


STUDENTS'  TEXT-BOOKS  AND  MANUALS.         0 

EYE. 

Hartridge  on  Refraction.    4th  Edition.  Cloth,  2.00 

Hartridge  on  the  Ophthalmoscope.  Nearly  Ready. 

Meyer.  Diseases  of  the  Eye.  A  complete  Manual  for  Stu- 
dents and  Physicians.  270  Illustrations  and  two  Colored  Plates. 
8vo.  Cloth,  4.50;  Leather,  5.50 

Swanzy.  Diseases  of  the  Eye  and  their  Treatment.  158 
Illustrations.  Third  Edition.  Cloth,  300 

Fox  and  Gould.  Compend  of  Diseases  of  the  Eye  and 
Refraction.  2d  Ed.  Enlarged.  71  Illus.  39  Formulae. 

Cloth,  i.oo ;  Interleaved  for  Notes,  1.25 

ELECTRICITY. 

Bigelow.  Plain  Talks  on  Medical  Electricity  and  Batteries. 

Illustrated.     With  a  Glossary  of  Electrical  Terms.       Cloth,  i.oo 

Mason's  Compend  of  Medical  and  Surgical   Electricity. 

With  numerous  Illustrations.     i2ino.  Cloth,  i.oo 

HYGIENE. 

Parkes'  (Ed.  A.)  Practical  Hygiene.  Seventh  Edition,  en- 
larged. Illustrated.  8vo.  Cloth,  4.50 

Parkes'  (L.  C.)  Manual  of  Hygiene  and  Public  Health. 
Second  Edition,  izmo.  Cloth,  2.50 

Wilson's  Handbook  of  Hygiene  and  Sanitary  Science. 
Seventh  Edition.  Revised  and  Illustrated.  In  Press. 

MATERIA  MEDICA  AND  THERAPEUTICS. 

Potter's  Compend  of  Materia  Medica,  Therapeutics  and 
Prescription  Writing.  Fifth  Edition,  revised  and  improved. 
See  Page  15.  Cloth,  i.oo;  Interleaved  for  Notes,  1.25 

Biddle's  Materia  Medica.  Eleventh  Edition.  By  the  late 
John  B.  Biddle,  M.D.,  Prof,  of  Materia  Medica  in  Jefferson  Col- 
lege, Philadelphia.  Revised  by  Clement  Biddle,  M.D.,  and 
Henry  Morris,  M.D.  8vo.,  illustrated.  Cloth,  4-25:  Leather,  5.00 

Potter.  Handbook  of  Materia  Medica,  Pharmacy  and 
Therapeutics.  Including  Action  of  Medicines,  Special  Thera- 
peutics, Pharmacology,  etc.  By  Saml.  O.  L.  Potter,  M.D., 
M  R.C.P.  (Lond.),  Professor  of  the  Practice  of  Medicine  in 
Cooper  Medical  College,  San  Francisco.  Third  Edition.  8vo. 

Cloth,  4.00;  Leather,  5.00 

Waring.      Therapeutics.      With  an    Index   of   Diseases    and 
Remedies.     4th  Edition.     Revised.      Cloth,  3.00;  Leather,  3.50 
*?•  See  pages  14  and  /j  for  list  of  t  Q*i»-  Contends  t 


10       STUDENTS'  TEXT-BOOKS  AND  MANUALS. 

MEDICAL  JURISPRUDENCE. 

Reese.  A  Text-book  of  Medical  Jurisprudence  and  Toxi- 
cology. By  John  J.  Reese,  M.D.,  Professor  of  Medical  Juris- 
prudence and  Toxicology  in  the  Medical  Department  of  the 
University  of  Pennsylvania ;  President  of  the  Medical  Juris- 
prudence Society  of  Philadelphia ;  Physician  to  St.  Joseph's 
Hospital ;  Corresponding  Member  of  The  New  York  Medico- 
legal  Society.  Third  Edition.  Cloth,  3.00;  Leather,  3.50 

OBSTETRICS  AND   GYNAECOLOGY. 

Davis.  A  Manual  of  Obstetrics.  Colored  Plates,  and  150 
other  Illustrations.  Ready  in  October,  i8()l, 

Byford.  Diseases  of  Women.  The  Practice  of  Medicine  and 
Surgery,  as  applied  to  the  Diseases  and  Accidents  Incident  to 
Women.  By  W.  H.  Byford,  A.M.,  M.D.,  Professor  of  Gynaecology 
in  Rush  Medical  College  and  of  Obstetrics  in  the  Woman's  Med- 
ical College,  etc.,  and  Henry  T.  Byford,  M.D.,  Surgeon  to  the 
Woman's  Hospital  of  Chicago.  Fourth  Edition.  Revised  and 
Enlarged.  306  Illustrations,  over  100  of  which  are  original. 
Octavo.  832  pages.  Cloth,  5^x3  ;  Leather,  6.00 

Cazeaux  and  Tarnier's  Midwifery.  With  Appendix,  by 
Munde.  The  Theory  and  Practice  of  Obstetrics  ;  including  the 
Diseases  of  Pregnancy  and  Parturition,  Obstetrical  Operations, 
etc.  Eighth  American,  from  the  Eighth  French  and  First 
Italian  Edition.  Edited  by  Robert  J.  Hess,  M.D.,  Physician  to 
the  Northern  Dispensary,  Philadelphia,  with  an  appendix  by 
Paul  F.  Munde,  M.D.,  Professor  of  Gynaecology  at  the  N.  Y. 
Polyclinic.  Illustrated  by  Chromo-Lithographs,  and  other  Full- 
page  Plates,  seven  of  which  are  beautifully  colored,  and  numerous 
Wood  Engravings.  One  Vol.,  8vo.  Cloth,  5.00;  Leather,  6.00 

Lewers'  Diseases  of  'Women.  A  Practical  Text-Book.  139 
Illustrations.  Second  Edition.  Cloth,  2.50 

Parvin's  Winckel's  Diseases  of  Women.  Second  Edition. 
Including  a  Section  on  Diseases  of  the  Bladder  and  Urethra. 
150  Illus.  Revised.  See  page  3.  Cloth,  3.00;  Leather,  3.50 

Morris.     Compend  of  Gynaecology.     Illustrated.      Cloth,  i.oo 

Winckel's  Obstetrics.  A  Text-book  on  Midwifery,  includ- 
ing the  Diseases  of  Childbed.  By  Dr.  F.  Winckel,  Professor 
of  Gynaecology,  and  Director  of  the  Royal  University  Clinic  for 
Women,  in  Munich.  Authorized  Translation,  by  J.  Clifton 
Edgar,  M.D.,  Lecturer  on  Obstetrics,  University  Medical  Col- 
lege, New  York,  with  nearly  200  handsome  illustrations,  the 
majority  of  which  are  original.  Svo.  Cloth,  6.00  ;  Leather,  7.00 

Landis'  Compend  of  Obstetrics.  Illustrated.  4th  edition, 
enlarged.  Cloth,  i.oo;  Interleaved  for  Notes,  1.25 

Galabin's  Midwifery.  By  A.  Lewis  Galabin,  M.D.,  F.R.C.P. 
227  Illustrations.  See  page  3.  Cloth,  3.00;  Leather,  3.50 

Rigby's  Obstetric  Memoranda.     4th  Edition.  Cloth,  .50 

<£9~  See  pages  2  to  5  for  list  of  New  Manuals. 


STUDENTS'  TEXT-BOOKS  AND  MANUALS.        11 

PATHOLOGY.    HISTOLOGY.    BIOLOGY. 

Bowlby.    Surgical   Pathology  and  Morbid  Anatomy,  for 
Students.     135  Illustrations,     121110.  Cloth,  2.00 

Davis'  Elementary  Biology.     Illustrated.  Cloth,  4.00 

Gilliam's  Essentials  of  Pathology.    A  Handbook  for  Student*. 
47  Illustrations.     I2mo.  Cloth,  a.o» 

***  The  object  of  this  book  is  to  unfold  to  the  beginner  the  funda- 
mentals of  pathology  in  a  plain,  practical  way,  and  by  bringing 
them  within  easy  comprehension  to  increase  his  interest  in  the  study 
of  the  subject. 

Gibbes'  Practical  Histology  and  Pathology.    Third  Edition. 

Enlarged.     121110.  Cloth,  1.75 

Virchow's  Post-Mortem  Examinations,     sd  Ed.    Cloth,  i.oo 

PHYSICAL  DIAGNOSIS. 

Fenwick.     Student's   Guide   to   Physical   Diagnosis.     7th 
Edition.     117  Illustrations.     I2mo.  Cloth,  2.25 

Tyson's  Physical  Diagnosis.     Illustrated. 

To  be  ready,  October,  I&QI. 

PHYSIOLOGY. 


pages.  321  carefully  printed  Illustrations.  With  a  Full 
Glossary  and  Index.  See  Page  3.  Cloth,  3.00;  Leather,  3.50 

Brubaker's  Compend  of  Physiology.  Illustrated.  Sixth 
Edition.  Cloth,  i.oo;  Interleaved  for  Notes,  1.25 

Stirling.  Practical  Physiology,  including  Chemical  and  Ex- 
perimental Physiology.  142  Illustrations.  Cloth,  2.25 

Kirke's  Physiology.  New  mh  Ed.  Thoroughly  Revised  and 
Enlarged.  502  Illustrations.  Cloth,  4.00;  Leather,  5.00 

Landois'  Human  Physiology.  Including  Histology  and  Micro- 
scopical Anatomy,  and  with  special  reference  to  Practical  Medi- 
cine. Third  Edition.  Translated  and  Edited  by  Prof.  Stirling. 
692  Illustrations.  Cloth,  6.50;  Leather,  7.50 

"  With  this  Text-book  at  his  command,  no  student  could  fail  in 

his  examination." — Lancet. 

Sanderson's  Physiological  Laboratory.  Being  Practical  Ex- 
ercises for  the  Student.  350  Illustrations.  8vo.  Cloth,  5.00 

PRACTICE. 

Taylor.  Practice  of  Medicine.  A  Manual.  By  Frederick 
Taylor,  M.D.,  Physician  to,  and  Lecturer  on  Medicine  at,  Guy's 
Hospital,  London  ;  Physician  to  Evelina  Hospital  for  Sick  Chil- 
dren, and  Examiner  in  Materia  Medica  and  Pharmaceutical 
Chemistry,  University  of  London.  Cloth,  4.00;  Leather,  5.00 

ee  pages  14  and  IS  for  list  of  t  Quix-  Commends  t 


12       STUDENTS'  TEXT-BOOKS  AND  MANUALS. 

Practice  : —  Continued. 

Roberts'  Practice.  New  Revised  Edition.  A  Handbook 
of  the  Theory  and  Practice  of  Medicine.  By  Frederick  T. 
Roberts,  M.D.  ;  M.R.C.P.,  Professor  of  Clinical  Medicine  and 
Therapeutics  in  University  College  Hospital,  London.  Seventh 
Edition.  Octavo.  Cloth,  5.50  ;  Sheep,  6.50 

Hughes.  Compend  of  the  Practice  of  Medicine.  4th  Edi- 
tion. Two  parts,  each,  Cloth,  i.oo;  Interleaved  for  Notes,  1.25 
PART  i. — Continued,  Eruptive  and  Periodical  Fevers,  Diseases 

of  the  Stomach,  Intestines,  Peritoneum,  Biliary  Passages,  Liver, 

Kidneys,  etc.,  and  General  Diseases,  etc. 

PART   n. — Diseases   of   the   Respiratory    System,   Circulatory 

System  and  Nervous  System;  Diseases  of  the  Blood,  etc. 
Physicians' Edition.    Fourth  Edition.    Including  a  Section 
on  Skin  Diseases.  With  Index,    i  vol.  Full  Morocco,  Gilt,  2.50 

From  John  A.  Robinson,  M.D.,  Assistant  to   Chair  of  Clinical 
Medicine,  now  Lecturer  on  Materia  Medico.,  Rush  Medical  Col- 
lege, Chicago. 
"  Meets  with   my  hearty  approbation  as  a  substitute  for  the 

ordinary  note  books  almost  universally  used  by  medical  students. 


:d  by  i 
ucid, 


It  is  concise,  accurate,  well  arranged  and  lucid,  .  .  .  just  the 
thing  for  students  to  use  while  studying  physical  diagnosis  and  the 
more  practical  departments  of  medicine." 

PRESCRIPTION   BOOKS. 

Wythe's  Dose  and  Symptom  Book.  Containing  the  Doses 
and  Uses  of  all  the  principal  Articles  of  the  Materia  Medica,  etc. 
Seventeenth  Edition.  Completely  Revised  and  Rewritten.  Just 
Ready.  32010.  Cloth,  i.oo;  Pocket-book  style,  1.25 

Pereira's  Physician's  Prescription  Book.  Containing  Lists 
of  Terms,  Phrases,  Contractions  and  Abbreviations  used  in 
Prescriptions  Explanatory  Notes,  Grammatical  Construction  of 
Prescriptions,  etc.,  etc.  By  Professor  Jonathan  Pereira,  M.D. 
Sixteenth  Edition.  32010.  Cloth,  i.oo;  Pocket-book  style,  1.25 

PHARMACY. 

Stewart's  Compend  of  Pharmacy.  Based  upon  Remington's 
Text-Book  of  Pharmacy.  Third  Edition,  Revised.  With  new 
Tables,  Index,  Etc.  Cloth,  i.oo;  Interleaved  for  Notes,  1.25 

Robinson.  Latin  Grammar  of  Pharmacy  and  Medicine. 
By  H.  D.  Robinson,  PH.D.,  Professor  of  Latin  Language  and 
Literature,  University  of  Kansas,  Lawrence.  With  an  Intro- 
duction by  L.  E.  Sayre,  PH.G.,  Professor  of  Pharmacy  in,  and 
Dean  of,  the  Dept.  of  Pharmacy,  University  of  Kansas.  I2mo. 

Cloth,  2.00 

SKIN  DISEASES. 

Anderson,  (McCall)  Skin  Diseases.  A  complete  Text-Book, 
with  Colored  Plates  and  numerous  Wood  Engravings.  8vo. 

Cloth,  4.50;  Leather,  5.50 

Van  Harlingen  on  Skin  Diseases.  A  Handbook  of  the  Dis- 
eases of  the  Skin,  their  Diagnosis  and  Treatment  (arranged  alpha- 
betically). By  Arthur  Van  Harlingen,  M.D.,  Clinical  Lecturer 
on  Dermatology,  Jefferson  Medical  College ;  Prof,  of  Diseases  of 
the  Skin  in  the  Philadelphia  Polyclinic.  2d  Edition.  Enlarged. 
With  colored  and  other  plates  and  illustrations.  12010.  Cloth,  2.50 
ee  pages  i  to  5  for  list  of  New  Manuals. 


STUDENTS'  TEXT-BOOKS  AND  MANUALS.       13 

SURGERY   AND   BANDAGING. 

Moullin's  Surgery,  A  new  Text-Book.  500  Illustrations,  200  of 
which  are  original.  Cloth,  7.00;  Leather,  8.00 

Jacobson.  Operations  in  Surgery.  A  Systematic  Handbook 
for  Physicians,  Students  and  Hospital  Surgeons.  By  W.  H.  A. 
Jacobson,  B.A.,  Oxon.  F.R.C.S.  Eng. ;  Ass't  Surgeon  Guy's  Hos- 
pital ;  Surgeon  at  Royal  Hospital  for  Children  and  Women,  etc. 
199  Illustrations.  1006  pages.  8vo.  Cloth.  5.00;  Leather,  6.00 

Heath's  Minor  Surgery,  and  Bandaging.  Ninth  Edition.  142 
Illustrations.  60  Formulae  and  Diet  Lists.  Cloth,  2.00 

Horowitz's    Compend    of    Surgery,    Minor    Surgery   and 
Bandaging,    Amputations,    Fractures,    Dislocations,  Surgical 
Diseases,  and  the  Latest  Antiseptic  Rules,  etc.,  with  Differential 
Diagnosis  and  Treatment.     By  ORVILLB  HOKWITZ,  B.S.,  M.D., 
Demonstrator  of  Surgery,  Jefferson  Medical  College.    4th  edition. 
Enlarged  and  Rearranged.     136   Illustrations  and   84  Formulae. 
i2mo.        Cloth,  i.oo ;  Interleaved  for  the  addition  of  Notes,  1.25 
***  The  new  Section  on  Bandaging  and  Surgical  Dressings,  con- 
sists  of  32  Pages  and  41   Illustrations.     Every  Bandage  of  any 
importance   is  figured.     This,  with   the  Section  on  Ligation  of 
Arteries,  forms  an  ample  Text-book  for  the  Surgical  Laboratory. 

Walsham.  Manual  of  Practical  Surgery.  For  Students  and 
Physicians.  By  WM.  J.  WALSHAM,  M.D.,  P.R  c.s.,  Asst.  Surg. 
to,  and  Dem.  of  Practical  Surg.  in,  St.  Bartholomew's  Hospital, 
Surgeon  to  Metropolitan  Free  Hospital,  London.  With  236 
Engravings.  See  Page  a.  Cloth,  3.00;  Leather,  3.50 

URINE,  URINARY   ORGANS,  ETC. 

Holland.  The  Urine,  and  Common  Poisons  and  The 
Milk.  Chemical  and  Microscopical,  for  Laboratory  Use.  Illus- 
trated. Fourth  Edition.  I2mo.  Interleaved.  Cloth,  i.oo 

Ralfe.  Kidney  Diseases  and  Urinary  Derangements.  42  Illus- 
trations. i2mo.  572  pages.  Cloth,  2.75 

Marshall  and  Smith.  On  the  Urine.  The  Chemical  Analysis  of 
the  Urine.  By  John  Marshall,  M.D.,  Chemical  Laboratory,  Univ. 
of  Penna ;  and  Prof.  E.  F.  Smith,  PH.D.  Col.  Plates.  Cloth,  i.oo 

Tyson.  On  the  Urine.  A  Practical  Guide  to  the  Examination 
of  Urine.  With  Colored  Plates  and  Wood  Engravings.  7th  Ed. 
Enlarged,  izmo.  Cloth,  1.50 

Van  Niiys,  Urine  Analysis.    Illus.  Cloth,  2.00 

VENEREAL  DISEASES. 

Hill  and  Cooper.  Student's  Manual  of  Venereal  Disease!, 
with  Formulae.  Fourth  Edition.  i2mo.  Cloth,  i.o» 

e  pages  14  and rj  for  list  of  .'  Qw*-Comj>t*d*  t 


JUST  PUBLISHED. 


GOULD'S  NEW 

MEDICAL  DICTIONARY 


COMPACT. 


GOiNGISE. 


PRACTICAL. 


ACCURATE. 


COMPREHENSIVE 


UP  TO  DATE. 


It  contains  Tables  of  the  Arteries,  Bacilli,  Gan- 
glia,   LeucomaTnes,    Micrococci,    Muscles, 
Nerves,    Plexuses,     Ptomaines,    etc., 
etc.,  that  will  be  found  of  great 
use   to   the    student. 


Small  octavo,  520  pages,  Half-Dark  Leather,      .     $3.25 
With  Thumb  Index,  Half  Morocco,  marbled  edges,  4.25 


From  J.  M.  DACOSTA,  M.  D.,  Professor  of  Practice  and 
Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia. 

"I find  it  an  excellent  work,  doing  credit  to  the  learning  and 
discrimination  of  the  author." 

***  Sample  Pages  free. 


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